Address

Telephone (day)		Fax
Telephone (evening)		Email
Date of Birth		Passport Number
Age now		Gender	MaleFemale
Marital Status	Single Married Divorced Separated

Date you wish to start:
-- 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 January February March April May June July August September October November December 2008 2009 2010

How long do you wish to stay?

3 months 4 months 5 months 6 months 7 months 8 months 9 months 10 months 11 months 12 months More than a year

What is your present job?

	Can you drive a car?
	Are you prepared to drive in Britain if necessary?

What language do you speak at home?

What other languages (apart from English) can you speak?

How well do you manage in the following areas?

	Poor	Good	Very Good
Cleaning House
Preparing Meals
Cooking / Baking
Ironing
Organising

	Are you prepared to do housework?
	Are you prepared to work with children?

Au pairs are not expected to take sole charge of babies under 2 years of age.
However, if you have had this experience and are prepared to support a parent then please give details:

Please tick the boxes for age groups of children you are prepared to work with:

	2 to 5
	5 to 9
	9 to 13
	Teenagers (13+)

Please give details of any experience working with children:

Are you prepared to help in a single parent family?

	Yes, any
	Yes, but only Father
	Yes, but only Mother
	No

Are you confident to work in a family with handicapped children?

We are a multi-cultural society in Britain, so it is expected that you will work in different types of ethnic families. Select as many as possible to increase your opportunities:

	White European
	African
	Asian
	Other

If you have a preference, please give a reason:

Do you have any health problems or allergies, that the family should know about?

	Are you a vegetarian?
	Do you smoke?
	NB: All smokers will be expected to smoke outside and not in front of the children.

Have you ever been convicted of a criminal offence? Please give details:

Do you like pets?

What kind of location(s) are you happy to live in?

	Countryside
	Village
	Suburb
	Town
	City

Tell a little about your family:

Tell a little about your church:

How often do you attend?

How did you first become a Christian?

What are your hobbies and interests?

Have you been on any courses for Health and Safety in the home?

How good is your English? Have you passed any relevant examinations?

Are you able to hold a basic conversation in English?

What is your main reason for coming to England?

Where did you hear about us?

	Friend
	Search Engine
	Another website
	Magazine
	Other

Please give details: (ie name of magazine, etc)

After submitting your application form, you will be sent 3 further forms to be filled in: a Medical certifcate, a Character reference and a Child-care reference. You should return these forms as quickly as possible along with your registration money of €30 or the equivalent exchange rate, plus 2 photographs of yourself. This will be your only cost.

Allow Christian Au Pairs to pass my details to other au pairs in the area?

I have read and accept the terms and conditions of Christian Au Pairs and agree that as an au pair, I will do my very best to follow all the guidelines as laid down. I acknowledge that Christian Au Pairs is under no liability to me in respect of any arrangements made between myself and a family.