* = required field

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

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