I would like to work as au-pair in

 for months

Would you like to start as soon as possible:

  Yes  No

If No, when would you like to start:

First name: 

Last name:    

Sex:     Female        Male

Address:  

Date of birth:

City:       

Age:              

Zip code:

Phone:          

Country:

Cell phone:   

E-mail:   

Citizenship:    

Marital status:  Married   Divorced

 Unmarried

Do you have any brothers or sisters:

 Yes No

If Yes, how many and what are their ages:

Do you have any experience with children or worked with kids before:

 Yes No

If Yes, what age were they at that time:

  What year(s):

Do you have a driving licence:     Yes

 No

Do you have a criminal record:   Yes

 No

Do you smoke:    Yes   No

Education:   Elementary school:

From: To:

                   High school:

From: To:

                   College:

From: To:

Other education:

Profession as                                          (name the last three employments) :

     From:

   To: 

     From:

   To: 

     From:

   To: 

Have you worked as au-pair or nanny before:

  Yes  No

If Yes, please name them with phone numbers:

             Phone:

             Phone:

             Phone:

Tell us something about your personality which might be useful for your future host family:

Are you allergic against something:

 Yes No      If yes, what:

What child diseases have you had:

Have you had any serious sickness lately:

 Yes No      If yes, what:

What languages do you speak, besides your own:

I would be interested in a language class to improve my:

Can you swim:    Yes   No

Are you a vegetarian:  Yes No

Do you like pets:  Yes   No

Write a short “Dear family”-letter to your future host family where you tell something about your hobbies and personal interests:

The best time to reach me is: