Address

Telephone (day)		Fax
Telephone (evening)		Email
Father's Profession		Ethnic origin
Mother's Profession		Number of Children
Marital Status	Single Married Divorced Separated

Children's names, birth dates, gender

Is a new baby expected? If so, when?

Any physical or mental disabilities the au pair would need to know about?

Type of school the children attend (eg nursery / state school / private / boarding)

Any other persons living in your household?

Main language spoken at home

English

Other

Any other languages spoken?

Date the au pair is required
-- 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 is the au pair required?

3 months 6 months 9 months 12 months More than a year

	Is a driving licence essential?
	Is a car available off duty as well as on duty?

What are the principle duties you wish the au pair to cover?

	Washing Dishes		Ironing
	Preparing Meals		Vacuuming
	Dusting & Polishing		Child-minding
	Other

Have you had an au pair recently?

If so, did you use our agency, another agency, or a private arrangement?
Our agency Another agency Private Arrangement

Do you have any other domestic help?

Does any member of your family smoke?
If so, please give details. (eg Do you smoke in the house?)

Do you have any pets? Please give details.

Daily duties of the au pair:
Average weekly schedule (blank schedules represent time off)

	Mon	Tue	Wed	Thur	Fri	Sat	Sun
Morning	WorkBaby-sit	WorkBaby-sit	WorkBaby-sit	WorkBaby-sit	WorkBaby-sit	WorkBaby-sit	WorkBaby-sit
Afternoon	WorkBaby-sit	WorkBaby-sit	WorkBaby-sit	WorkBaby-sit	WorkBaby-sit	WorkBaby-sit	WorkBaby-sit
Evening	WorkBaby-sit	WorkBaby-sit	WorkBaby-sit	WorkBaby-sit	WorkBaby-sit	WorkBaby-sit	WorkBaby-sit

For extra details, or if a more flexible arrangement is required, please indicate below:

Important: Will the au pair regularly be left in sole charge of the children?
Please write specific times and duties required:

Is your home situated in:

	Countryside
	Village
	Suburb
	Town
	City

If you are not living in a town/city, what is the name and distance to the nearest town?

How far is the nearest public transport?

Shopping distance?

What social/recreational activities are available?

Please write a short description of your home:

Please describe the au pair's room:

Are you practising Christians?

Where is your place for worship? How regularly do you attend?

Could you describe your church for the au pair? (type of church, activities, age groups, focus, etc..)

Is the gender of the au pair important?

No Yes, male Yes, female

How much pocket money would you pay your au pair?

Where did you hear about us?

	Friend
	Search Engine
	Another website
	Magazine
	Other

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

I have read and accept the terms and conditions of Christian Au Pairs and agree that an au pair will be treated as a member of my family and be under my guidance. I agree to treat information regarding applicants as strictly confidential. I acknowledge that Christian Au Pairs is under no liability to me in respect of any arrangements made by me with any au pair.

When we have received your application form, we will send to you a Character Reference to be filled in by your pastor, priest or church leader. Please return the filled in Reference along with your registration fee of £25 and family photograph.