First Name... Last Name... Middle Name... Street Address 1... Street Address 2... City... Postal Code... Country
AU PAIR 1. PERSONAL INFORMATION Name First Name ....................................................................................... Last Name .......
AU PAIR 1. PERSONAL INFORMATION Name First Name ....................................................................................... Last Name .................................................................................. Middle Name ..................................................................................
Address Street Address 1 .............................................................................. Street Address 2 ......................................................................... City ................................................................................................. Postal Code ................................................................................ Country ..........................................................................................
Contact Details Email ............................................................................................... Skype ID .................................................................................... Phone:
Country Code ............. Phone Number ............................................ Best Time to Call ...............................................
Mobile Phone: Country Code ............. Phone Number ............................................ Best Time to Call................................................ Alt. Phone:
Country Code ............ Phone Number ............................................ Best Time to Call ...............................................
Notes on how to contact ..........................................................................................................................................................................................................
Other Personal Information Birth Date ........................................................................................ Sex
❏ Male ❏ Female
Country of Citizenship ..................................................................... Nationality ................................................................................. Birth City ......................................................................................... Birth Country ............................................................................. Country of Legal Residence ................................................................................................................................................................ First Available Arrival Date ..................................................................................................................................................................
2. CHILDCARE SKILLS Experience caring for children of these ages
Comfortable caring for children of these ages
❏ ❏ ❏ ❏ ❏ ❏ ❏
❏ ❏ ❏ ❏ ❏ ❏ ❏
0–6 months 6 –12 months 1– 2 years 2– 5 years 5 –10 years 10–15 years 15–18 years
0 – 6 months 6–12 months 1–2 years 2–5 years 5–10 years 10–15 years 15–18 years
www.sts.se
Please indicate the specialized skills you have as they relate to childcare
❏ ❏ ❏ ❏ ❏ ❏ ❏
Cooking First aid / lifesaving Nurses training Life Guarding Newborn classes Child development classes Teaching/Tutoring experience
Please describe your experience with household duties (cooking, cleaning, etc.): .......................................................................................................................................................................................................... .......................................................................................................................................................................................................... .......................................................................................................................................................................................................... ..........................................................................................................................................................................................................
Do you have experience with children with special needs / disabilities? (mental or physical disabilities)?
❏
Yes
❏
No
If yes, please provide details of your experience caring for children with mental or physical disabilities: ..........................................................................................................................................................................................................
Are you willing to care for children with special needs?
❏
Yes
❏
No
3. CHILDCARE EXPERIENCES CHILDCARE EXPERIENCE 1 AND 2 ARE MANDATORY TO FILL OUT AND NEED TO MATCH YOUR CHILDCARE REFERENCES. Childcare Experience – 1 MANDATORY ❏ Babysitting
Employer Info Employer Name .................................................................................................................................................................................. Phone: Country Code ......... Phone Number .......................................... Start Date.............................. End Date................................ How many hours per week (on average) did you work at this location? ................................................ Total hours?............................ Total number of hours caring for children under the age of two ............................................................................................................ Are you related to this employer? ........................................................................................................................................................ Children 1 Name ........................................................................................... Gender
❏ Male ❏ Female
Age of child at start .......................................................................... Age of child at end ..................................................................... 2 Name .......................................................................................... Gender
❏ Male ❏ Female
Age of child at start .......................................................................... Age of child at end .................................................................... 3 Name .......................................................................................... Gender
❏ Male ❏ Female
Age of child at start .......................................................................... Age of child at end ..................................................................... 4 or group/daycare How many children at this location .................................................. Gender
❏ Male ❏ Female
Age of youngest child at this location ............................................... Age of oldest child at this location ...............................................
www.sts.se
Primary Responsibilities at this Job
❏ ❏ ❏ ❏
❏ ❏ ❏ ❏
Bottle feeding Changing diapers (nappies) Meal preparation Putting children to bed
❏ ❏ ❏ ❏
Spoon feeding Bathing Playing with children Potty training
Burping Driving children to appointments / play dates Helping with schoolwork Supervising children at play / swimming
Describe your duties .......................................................................................................................................................................................................... .......................................................................................................................................................................................................... ..........................................................................................................................................................................................................
Employer Info Employer Name .................................................................................................................................................................................. Phone: Country Code ......... Phone Number .......................................... Start Date.............................. End Date................................ How many hours per week (on average) did you work at this location? ................................................ Total hours?............................ Total number of hours caring for children under the age of two ............................................................................................................ Are you related to this employer? ........................................................................................................................................................ Children 1 Name ........................................................................................... Gender
❏ Male ❏ Female
Age of child at start .......................................................................... Age of child at end ..................................................................... 2 Name .......................................................................................... Gender
❏ Male ❏ Female
Age of child at start .......................................................................... Age of child at end ..................................................................... 3 Name .......................................................................................... Gender
❏ Male ❏ Female
Age of child at start .......................................................................... Age of child at end ..................................................................... 4 or group/daycare How many children at this location .................................................. Gender
❏ Male ❏ Female
Age of youngest child at this location ............................................... Age of oldest child at this location ............................................... Primary Responsibilities at this Job
❏ ❏ ❏ ❏
Bottle feeding Changing diapers (nappies) Meal preparation Putting children to bed
❏ ❏ ❏ ❏
Spoon feeding Bathing Playing with children Potty training
❏ ❏ ❏ ❏
Burping Driving children to appointments / play dates Helping with schoolwork Supervising children at play / swimming
Describe your duties .......................................................................................................................................................................................................... .......................................................................................................................................................................................................... ..........................................................................................................................................................................................................
Employer Info Employer Name .................................................................................................................................................................................. Phone: Country Code ......... Phone Number .......................................... Start Date.............................. End Date................................ How many hours per week (on average) did you work at this location? ................................................ Total hours?............................
www.sts.se
Total number of hours caring for children under the age of two ............................................................................................................ Are you related to this employer? ........................................................................................................................................................ Children 1 Name ........................................................................................... Gender
❏ Male ❏ Female
Age of child at start .......................................................................... Age of child at end ..................................................................... 2 Name .......................................................................................... Gender
❏ Male ❏ Female
Age of child at start .......................................................................... Age of child at end .................................................................... 3 Name .......................................................................................... Gender
❏ Male ❏ Female
Age of child at start .......................................................................... Age of child at end ..................................................................... 4 or group/daycare How many children at this location .................................................. Gender
❏ Male ❏ Female
Age of youngest child at this location ............................................... Age of oldest child at this location ............................................... Primary Responsibilities at this Job
❏ ❏ ❏ ❏
Bottle feeding Changing diapers (nappies) Meal preparation Putting children to bed
❏ ❏ ❏ ❏
Spoon feeding Bathing Playing with children Potty training
❏ ❏ ❏ ❏
Burping Driving children to appointments / play dates Helping with schoolwork Supervising children at play / swimming
Describe your duties .......................................................................................................................................................................................................... .......................................................................................................................................................................................................... ..........................................................................................................................................................................................................
Employer Info Employer Name .................................................................................................................................................................................. Phone: Country Code ......... Phone Number .......................................... Start Date.............................. End Date................................ How many hours per week (on average) did you work at this location? ................................................ Total hours?............................ Total number of hours caring for children under the age of two ............................................................................................................ Are you related to this employer? ........................................................................................................................................................ Children 1 Name ........................................................................................... Gender
❏ Male ❏ Female
Age of child at start .......................................................................... Age of child at end ..................................................................... 2 Name .......................................................................................... Gender
❏ Male ❏ Female
Age of child at start .......................................................................... Age of child at end .................................................................... 3 Name .......................................................................................... Gender
❏ Male ❏ Female
Age of child at start .......................................................................... Age of child at end ..................................................................... 4 or group/daycare How many children at this location .................................................. Gender
❏ Male ❏ Female
Age of youngest child at this location ............................................... Age of oldest child at this location ...............................................
www.sts.se
Primary Responsibilities at this Job
❏ ❏ ❏ ❏
❏ ❏ ❏ ❏
Bottle feeding Changing diapers (nappies) Meal preparation Putting children to bed
Spoon feeding Bathing Playing with children Potty training
❏ ❏ ❏ ❏
Burping Driving children to appointments / play dates Helping with schoolwork Supervising children at play / swimming
Describe your duties .......................................................................................................................................................................................................... .......................................................................................................................................................................................................... ..........................................................................................................................................................................................................
Employer Info Employer Name .................................................................................................................................................................................. Phone: Country Code ......... Phone Number .......................................... Start Date.............................. End Date................................ How many hours per week (on average) did you work at this location? ................................................ Total hours?............................ Total number of hours caring for children under the age of two ............................................................................................................ Are you related to this employer? ........................................................................................................................................................ Children 1 Name ........................................................................................... Gender
❏ Male ❏ Female
Age of child at start .......................................................................... Age of child at end ..................................................................... 2 Name .......................................................................................... Gender
❏ Male ❏ Female
Age of child at start .......................................................................... Age of child at end ..................................................................... 3 Name .......................................................................................... Gender
❏ Male ❏ Female
Age of child at start .......................................................................... Age of child at end ..................................................................... 4 or group/daycare How many children at this location .................................................. Gender
❏ Male ❏ Female
Age of youngest child at this location ............................................... Age of oldest child at this location ............................................... Primary Responsibilities at this Job
❏ ❏ ❏ ❏
Bottle feeding Changing diapers (nappies) Meal preparation Putting children to bed
❏ ❏ ❏ ❏
Spoon feeding Bathing Playing with children Potty training
❏ ❏ ❏ ❏
Burping Driving children to appointments / play dates Helping with schoolwork Supervising children at play / swimming
Describe your duties .......................................................................................................................................................................................................... .......................................................................................................................................................................................................... ..........................................................................................................................................................................................................
Employer Info Employer Name .................................................................................................................................................................................. Phone: Country Code ......... Phone Number .......................................... Start Date.............................. End Date................................ How many hours per week (on average) did you work at this location? ................................................ Total hours?............................
www.sts.se
Total number of hours caring for children under the age of two ............................................................................................................ Are you related to this employer? ........................................................................................................................................................ Children 1 Name ........................................................................................... Gender
❏ Male ❏ Female
Age of child at start .......................................................................... Age of child at end ..................................................................... 2 Name .......................................................................................... Gender
❏ Male ❏ Female
Age of child at start .......................................................................... Age of child at end .................................................................... 3 Name .......................................................................................... Gender
❏ Male ❏ Female
Age of child at start .......................................................................... Age of child at end ..................................................................... 4 or group/daycare How many children at this location .................................................. Gender
❏ Male ❏ Female
Age of youngest child at this location ............................................... Age of oldest child at this location ............................................... Primary Responsibilities at this Job
❏ ❏ ❏ ❏
❏ ❏ ❏ ❏
Bottle feeding Changing diapers (nappies) Meal preparation Putting children to bed
❏ ❏ ❏ ❏
Spoon feeding Bathing Playing with children Potty training
Burping Driving children to appointments / play dates Helping with schoolwork Supervising children at play / swimming
Describe your duties .......................................................................................................................................................................................................... .......................................................................................................................................................................................................... ..........................................................................................................................................................................................................
4. EDUCATION General Education Information
❏ ❏ ❏
❏ ❏
High school (secondary school/gymnasium) Currently in university
Postgraduate Other
Completed university
When did you complete high school? .................................................................................................................................................. What was your primary field of study (your major subject)? .................................................................................................................
❏
What is your level of English?
Excellent
❏
Good
❏
Fair
❏
Poor
5. FAMILY INFORMATION Mother's Name .................................................................................................................................................................................. Occupation ........................................................................................................................................................................................ Father's Name .................................................................................................................................................................................... Occupation ........................................................................................................................................................................................ Do you have any sisters?
❏
Yes
❏
No
What are their names and ages? ......................................................................................................................................................... Do you have any brothers?
❏
Yes
❏
No
www.sts.se
What are their names and ages? ......................................................................................................................................................... Please describe your family .......................................................................................................................................................................................................... .......................................................................................................................................................................................................... .......................................................................................................................................................................................................... .......................................................................................................................................................................................................... .......................................................................................................................................................................................................... .......................................................................................................................................................................................................... EMERGENCY CONTACT INFORMATION Name ................................................................................................................................................................................................. Phone number ................................................................................................................................................................................... Email ..................................................................................................................................................................................................
6. DRIVING EXPERIENCE Do you have a valid driver's license?
❏
What year did you first begin to drive an automobile?
❏ Are you willing to drive as an au pair? ❏ Do you have experience from driving in snow? ❏ Do you have experience from driving with children in the car? ❏ What kind of roads do you usually drive on?
Yes
❏
No
❏
Country Yes Yes Yes
❏ ❏ ❏
City
❏
Highway
No No No
7. PERSONAL CHARACTERISTICS Can you swim?
❏
Yes
❏
No
Do you smoke?
❏
Yes
❏
No
Are you willing to live in a household with (check all that apply)
❏
Dog
❏
Cat
❏
Bird
❏
I am not willing to live with pets.
If you are not willing to live with pets, please describe ..........................................................................................................................................................................................................
What other languages besides English, do you speak? .........................................................................................................................
Please tell us about your hobbies and interests .......................................................................................................................................................................................................... .......................................................................................................................................................................................................... .......................................................................................................................................................................................................... ..........................................................................................................................................................................................................
www.sts.se
8. PERSONALITY Imagine your friend had to choose four words from the list below to describe you. Choose the four words they would pick.
❏ ❏ ❏ ❏ ❏
❏ ❏ ❏ ❏ ❏
Good listener Generous Loyal Physically fit Funny
Caring Intelligent Happy Dependable Affectionate
❏ ❏ ❏ ❏ ❏
Outgoing Passionate Hard working Spiritual
❏ ❏ ❏ ❏
Creative Modest Energetic Quiet
❏ ❏ ❏ ❏
Ambitious Optimistic Respectful Thoughtful
Easy going
9. SHORT ANSWER QUESTIONS Please answer the following questions in 50 words or less. Why should a family choose you as their au pair? .......................................................................................................................................................................................................... .......................................................................................................................................................................................................... Do you have any special talents or skills that would be useful when caring for children? .......................................................................................................................................................................................................... .......................................................................................................................................................................................................... When you return to your home country at the end of the program, what do you plan to do? .......................................................................................................................................................................................................... ..........................................................................................................................................................................................................
10. HEALTH Do you suffer from any chronic or recurring health problems, for example asthma, allergies, diabetes, epilepsy, or cold sores?
❏
Yes
❏
No
If Yes, give details. .................................................................................................................................................
Do you take any medications?
❏
Yes
❏
No
If Yes, give details. .................................................................................................................................................
Have you been hospitalized or in the care of a doctor in the last 12 months?
❏
Yes
❏
No
If Yes, give details. .................................................................................................................................................
Have you ever suffered from or received counseling or treatment for a nervous or emotional problem, for example depression or an eating disorder?
❏
Yes
❏
No
If Yes, give details. .................................................................................................................................................
Do you have any food allergies?
❏
Yes
❏
No
If Yes, give details...................................................................................................................................................
![Full Legal Name [ ] Miss [ ] Mrs. [ ] Mr. [ ] Rev. [ ] Dr. Last First Middle Maiden Name. Address. City State Zip Code. Country Telephone ( )](https://kipdf.com/img/300x300/full-legal-name-miss-mrs-mr-rev-dr-last-first-midd_5aaedda31723dd258ba90054.jpg)
