FIRST NAME:
SURNAME:
MIDDLE NAME(S):
FEMALE
MALE
CURRENT MAILING ADDRESS
(HOME) TELEPHONE NUMBER
CELL PHONE NUMBER
E-MAIL
SKYPE NAME
BIRTH DATE:
PLACE OF BIRTH:
COUNTRY OF BIRTH:
NATIONALITY:
ARE YOU, OR HAVE YOU EVER BEEN MARRIED?
YES
NO
IF YES, PLEASE SPECIFY:
DO YOU HAVE CHILDREN OF YOUR OWN?
YES
NO
HAVE YOU EVER BEEN PREGNANT?
YES
NO
IF YOU ANSWERED ‘YES’ TO ONE OF THE ABOVE QUESTIONS, PLEASE SPECIFY:
HAVE YOU EVER BEEN ARRESTED?
YES
NO
DO YOU HAVE ANY PHYSICAL DISABILTIES?
YES
NO
IF YES, PLEASE DESCRIBE YOUR DISABILITY AND HOW IT AFFECTS YOUR DAY-TO-DAY LIFE:
DO YOU ENJOY GOOD HEALTH?
YES
NO
IF NOT, PLEASE DESCRIBE YOUR HEALTH PROBLEMS:
HOW MANY DAYS HAVE YOU MISSED DUE TO ILLNESS IN THE PAST 12 MONTHS?
DO YOU USE ANY MEDICATION(S)?
IF YES, PLEASE SPECIFY WHAT KIND OF MEDICATION AND ON WHAT BASIS (I.E DAILY, WEEKLY, SEASONAL):
HAVE YOU BEEN TREATED FOR DEPRESSION OR MENTAL ILLNESS?
IF YES, PLEASE DESCRIBE THE SITUATION, HOW LONG AGO THIS WAS AND THE TREATMENT:
YES
NO
DO YOU SMOKE?
YES
NO
IF YES, HOW LONG DID YOU SMOKE?
CAN YOU DRIVE?
YES
NO
CAN YOU SWIM?
YES
NO
DO YOU HAVE ANY OTHER SKILLS WHICH MAY BE USEFUL AS AN AU PAIR?
IF YES, SPECIFY:
WHAT LANGUAGES DO YOU SPEAK?
ABOUT YOUR FAMILY:
FATHER (NAME, NATIONALITY AND OCCUPATION)
MOTHER (NAME, NATIONALITY AND OCCUPATION)
MY PARENTS ARE
DIVORCED
MARRIED
NAMES AND AGES OF BROTHERS:
NAMES AND AGES OF SISTERS:
PLEASE GIVE A SHORT DESCRIPTION OF YOUR FAMILY AND THE BOND YOU HAVE WITH THEM:
HAVE YOU EVER LIVED AWAY FROM HOME?
IF YES, PLEASE SPECIFY (FOR HOW LONG AND WHAT REASON):
RELIGION:
DO YOU EXPECT TO ATTEND RELIGIOUS SERVICES IN HOLLAND?
IF YES, PLEASE SPECIFY:
ANY DIETARY OR OTHER RESTRICTIONS BECAUSE OF YOUR RELIGION?
IF YES, PLEASE SPECIFY:
ARE YOU A STUDENT?
IF YES, SPECIFY:
IF YOU’RE NOT A STUDENT, WHAT IS YOUR PRESENT OCCUPATION?
IF YOU HAVE ANY WORK EXPERIENCE (APART FROM YOUR CHILDCARE EXPERIENCE), PLEASE SPECIFY;
JOB DESCRIPTION - YRS/MNTHS
DESCRIBE BELOW ALL YOUR CHILD CARE EXPERIENCE (LISTING AGES OF CHILDREN AND YOUR DUTIES) IN AS MUCH DETAIL AS POSSIBLE (PLEASE INCLUDE THE NUMBER OF HOURS PER WEEK SPENT WITH THE CHILDREN AND THE TOTAL PERIOD OF TIME INVOLVED)
ARE YOU PREPARED TO TAKE CARE OF A BABY (3 MONTHS - 1 YR OLD)? IF NOT, PLEASE SPECIFY:
I HAVE EXPERIENCE WORKING WITH:
I WOULD LIKE TO WORK WITH:
3 MONTHS – 1 YEAR
1-3 YEARS
4-7 YEARS
8-12 YEARS
3 MONTHS – 1 YEAR
1-3 YEARS
4-7 YEARS
8-12 YEARS
DO YOU HAVE EXPERIENCE WITH SPECIAL NEEDS CHILDREN?
IF YES, PLEASE SPECIFY:
WOULD YOU BE WILLING TO WORK WITH A SPECIAL NEEDS CHILD (AUTISTIC, PHYSICAL DISABILITY, MENTAL DISABILITY ETC.)?
WOULD YOU ACCEPT A SINGLE PARENT FAMILY?
ARE YOU PREPARED TO DO LIGHT HOUSEWORK?
BELOW IS AN OVERVIEW OF LIGHT HOUSEHOLD CHORES EXPECTED FROM YOU BY THE FAMILY, PLEASE LET US KNOW IF YOU’RE EXPERIENCED WITH ANY OF THESE CHORES.
ARE THERE ANY TYPE OF HOUSEHOLD CHORES THAT YOU DO NOT WISH TO DO? YES/NO
IF YES, PLEASE SPECIFY:
DO YOU KNOW HOW TO COOK? YES/NO
IF YES, PLEASE SPECIFY WHAT TYPE OF FOODS YOU NORMALLY COOK:
WOULD YOU ACCEPT A FAMILY WITH
DOGS?
CATS?
OTHER PETS?
IF NOT, PLEASE SPECIFY:
WOULD YOU BE WILLING TO HELP OUT WITH THE CARE OF PETS (I.E. WALK THE DOG, FEED THE CAT)?
PLEASE SPECIFY YOUR ANSWER:
WHAT ARE YOUR INTERESTS AND HOBBIES:
WHAT ARE YOUR BEST PERSONALITY TRAITS?
WHAT ARE YOUR WORST PERSONALITY TRAITS?
WHAT DO YOU CONSIDER TO BE APPROPRIATE DISCIPLINE TECHNIQUES FOR
YOUNG CHILDREN?
WHAT ARE YOUR FAVORITE ACTIVITIES TO DO WITH CHILDREN?
WHAT DO YOU LIKE BEST ABOUT TAKING CARE OF CHILDREN?
WHAT DO YOU LIKE LEAST ABOUT TAKING CARE OF CHILDREN?
IN YOUR OWN WORDS, EXPLAIN YOUR MOTIVATION TO BECOME AN AU PAIR IN HOLLAND, AND WHAT YOU HOPE TO FIND IN A HOST FAMILY:
WHAT DO YOU PLAN TO DO AFTER COMPLETING YOUR AU PAIR ASSIGNMENT?
EARLIEST POSSIBLE DATE OF DEPARTURE :
LATEST POSSIBLE DATE OF DEPARTURE:
CAN YOU STAY FOR 12 MONTHS?
IF NOT, HOW LONG WOULD YOU BE PREPARED TO STAY?
