*Your Name

*Sex Female Male

*No./Street

*Town

*County

*Postcode

*Home Telephone

Mobile Phone

Work Telephone

*Email Address

Skype

Messenger ID

Nationality of Parents

Parents age
(please indicate age of both parents)

What is your religion? Christian Catholic Muslim Sikh Jewish Buddist Other Not Religious

Do you practice your religion? No Yes

Number of Adults 1 2 3 4 5

Number of Children No Kids 1 2 3 4 5

Names and Sex of Children

Age of children (tick all) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
(hold ctrl and mouse to select more than one)

Mother's Occupation

Father's Occupation

Do you or your partner do shiftwork? No Yes

Are you a single parent? No Yes

Are you expecting a new baby? No Yes

Do you have any special care needs? No Yes

Please outline any special needs
(e.g. health, allergies, other special needs)

Previously had an Au Pair? Yes No

Number of bedrooms 1-2 3-4 5+

Briefly describe your home
(e.g. size, gardens, facilities, location of house)

Describe the Au Pairs accommodation

Where do you live? Village Semi rural Rural Suburbs Small town urban centre

How far is your home from facilities?
(e.g. to bus, train, town, college)

Summarise your family interests?
(e.g. interests, hobbies, activities)

Do you have any pets?
(specify)

Do you have any existing help? No Cleaner Childminder Nanny
(hold ctrl and mouse to select more than one)

*Start date
(Day/Month/Year)

*Type of Au Pair Au Pair (up to 25 hours) Au Pair Plus (up to 35 hours) Mother's Help (up to 45 hours)

*Required number of hours
(specify number of hours per day and total for week)

*Length of placement 1 - 3 months 3 - 6 months 6-12 months 12 months +

Preferred age range of Au Pair 18-21 22-24 25-27 Any/don't mind

Which Au Pair nationality would you consider? Austrian Czech French German Hungarian Italian Polish Romanian Spanish Swedish Any/no preference
(hold ctrl and mouse to select more than one)

Would you take a male Au Pair? Yes Maybe No

What is the focus of the Au Pair? more focused on childcare equally focused on childcare and housework more focused on housework

*How much housework do you need? Light (1 hour a day) Medium (up to 2 hours a day) Heavy (3 hours a day or more)

*Housework duties
(specify duties you would like)

Do you need a swimmer? Essential Desirable Not necessary

Do you need a driver? Essential Desirable Not necessary

Level of English needed Basic Good Fluent

Do you require babysitting? Regularly Occasionally Not needed

Do you mind if Au Pair has special diet needs? Don't mind Depends on diet / candidate Prefer not

Do you mind Vegetarians? Don't mind Prefer not

Would you accept a smoker? Yes Yes, if smoke outside No

Do they need to cook? Essential Desirable Not necessary

Describe ideal Au Pair personality for your family?

What are the key attributes or preferences you need the Au Pair to have?

*How much pocket money are you offering? £70-80 £81-90 £91-100 £101-110 £111-120 £121+

What other incentives, if any, are you offering? None access to pc access to laptop broadband mobile phone mobile phone credits extra holiday
(hold ctrl and mouse to select more than one)

*Will you contribute to any of the following Travel costs of Au Pair to UK Travel costs in UK (e.g. bus, train) Local college English classes None of these
(hold ctrl and mouse to select more than one)

*I accept the company Terms and Conditions Yes No

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