| Contact Name (Full Name) |
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| Surname |
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| First Name |
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| Address |
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| Email |
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| Mobile |
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| Telephone (Landline) |
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| Who should be the primary contact (Mother/Father)? |
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| What language is mainly spoken in the home? |
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| Where did you hear of us? * |
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| Number of children? |
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| 1st Child’s Name |
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| 1st Child’s Date of Birth |
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| 2nd Child’s Name |
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| 2nd Child’s Date of Birth |
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| 3rd Child’s Name |
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| 3rd Child’s Date of Birth |
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| 4th Child’s Name |
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| 4th Child’s Date of Birth |
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| 5th Child’s Name |
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| 5th Child’s Date of Birth |
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| Does any of your children have any disabilities or allergies that would require specific attention? |
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| Are there any aspects of family life which should be given consideration (e.g. vegetarian diet etc.) |
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| Other Persons Living With You? |
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| If Yes Please give details (Name, Age, Relationship) |
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| Type of home location (select one that best describes your location) |
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| Location |
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| Is there public transport from your house into the town/city centre? |
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| Have you had an au pair before? |
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| Distance from your home to the centre of the city (in miles) |
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| Distance from your home to the nearest language school (in miles) |
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| Will your Au Pair be able to attend English classes while she/he is with you? |
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| If Yes will you make a contribution towards the cost of these classes? |
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| If Yes then what % of the class fees will you cover? |
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| Do you require an au pair that can drive? |
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| Requested Start Date |
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| Length of Stay (in months) |
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| What age au pair would you be comfortable with? |
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| Would you like an au pair to stay over |
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| Would you accept an au pair that smokes? |
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| Would you consider a male au pair? |
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| Do you require your au pair to have any special skills (swimming, horse riding, piano etc.)? Please |
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| Does any of your family smoke at home? |
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| Character (choose 5 key aspects of personality you consider important in an au pair) |
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| Do you have pets? |
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| Will the Au Pair be required to care for any pets? |
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| Host Mother’s Daily Schedule (working hours, do you have to work weekends?, do you travel away |
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| Host Father’s Daily Schedule (working hours, do you have to work weekends?, do you travel away |
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| Children’s Daily Schedule (name of child, detail of time of school attendance and other activi |
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| Duties |
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| Salary |
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| Total Hours Work |
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| Details of any other benefits (i.e. mobile phone/phone allowance, car provided, fuel allowance, bus |
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| Personal use of car provided |
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| About your Families Hobbies and Interests |
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| Description of House, Au Pair Room, Location or other aspects of your family |
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| Comments - Considerations - Special Requests |
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| Does any member of your family have a criminal conviction? |
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