Personal details. Country currently living in: General questions

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Klaudia Antczak
8 lat temu
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1 Application Form for Au Pair/ Mother s Help 3 page application form Dear Family letter write about your home, family, education, childcare experience, hobbies at least 200 words 2 references At least 1 reference must be childcare related but these cannot be from family member forms supplied Photos of you with children/ family/ friends Medical Questionnaire form supplied Police check visit your local police station and apply for certificate to show any criminal history Personal details Name Female Male Nationality Contact details Phone: Mobile: Country currently living in: Skype : Age and date of birth Date of Birth Age Fax: Nationality and Passport number Nationality Passport number Marital status: Married Single Boyfriend/Girlfriend Divorced What type of location do you currently live in? City Town Village Countryside General questions Do you drive? Yes No Date when test passed: Have you had any accidents or convictions? Yes No How often? daily: Weekly: Monthly: Type of Roads? City Town: Rural Yes Do you smoke Yes No If yes, will you agree to not smoke in the house or around the kids? Yes No Available from-until From: Until: The longer you can stay the better it is Where do you wish to work? Please X all that apply Positions Sought Please X all that apply Definition of Roles Pocket money/ salary weekly Have you got any brothers or sisters? If yes, please specify. How well do you speak English? Do you wish to attend English classes? Do you like pets? Yes No Care for pets? Yes No FLEXIBLE City Town Village UK Countryside Scotland Ireland Specific location: Au-pair Au-pair + Mothers help, only if you have 1 year + experience with children Au Pair, hours, 2 free days and (up to) 2 nights babysitting, pocket money from 70 Au Pair plus, hours, 2 free days and (up to) 3 nights babysitting, pocket money from 80 Mother s help, hours per week with at least 1 day off Name and age: 2.Name and age: 3.Name and age: 4.Name and age: Poor Adequate Good Very good FLEXIBLE Yes No

local police station and apply for certificate to show any criminal history Personal details Name Female Male Nationality Contact details Phone: Mobile: Country currently living in: E-mail: Skype :

2 Are you in perfect Yes No health? Allergies etc. Please give details. Specific food Yes No requirements? (Vegetarian etc) Please give details. Can you swim? Yes No Have you ever lived away from your family and friends? If yes, please specify. Will you accept a family that is not British? Will you accept Single Parent? What duties are you prepared to do? Please X as many as apply. The more you tick the more choice of family you ll get Please tell us briefly about your hobbies and interests: Please state what qualities you find most important in yourself. ( Ex. Reliable, flexible etc) Please give brief details of your education, how long you have studied for and examinations you have passed. Please give details of any other qualifications such as First aid certificates etc. Are you experienced with the following? Please give brief details of your current childcare experience, including babysitting, summer camp. Ages of children etc. Yes No FLEXIBLE Yes No Yes, if they speak English at home FLEXIBLE Yes No Single mother only Cook Tidy/Clean children s rooms Hoover Supervise homework Supervise bedtime Baby-sit Wash up after meals Wash Children s clothes Iron Help with shopping Tidy/dust Education and qualifications Childcare Experience Babies under 6 months Yes No Happy to learn Toddlers Yes No Happy to learn School aged children? Yes No Happy to learn What age of children do you prefer?

3 Why do you want become an au-pair? Brief description Write at least 5-10 lines. More information can be detailed on your Dear family letter. How did you hear about Au Pair Programme? Please be helpful and tell us how you heard about us. If you were referred by someone who has used our services before, please give name. Thank you! I here declare the information on this application form is correct. Signature: Date: Biuro Wyjazdów Zagranicznych KANGIEL ul. Karczówkowska 5A, pok Kielce info@kangiel.pl tel Please now complete PART 2 OF THE FORM AS SOON AS POSSIBLE AND THEN RETURN TO US WE CANNOT OFFER YOU A FAMILY UNTIL WE HAVE YOUR FULL APPLICATION FORM

If you were referred by someone who has used our services before, please give name. Thank you! I here declare the information on this application form is correct.

4 Childcare reference This person is applying to be an au pair in Britain (Ta osoba ubiega się o udział w programie Au Pair w Wielkiej Brytanii) Au pair name Date of Birth We know this person as our (znamy tę osobę jako naszą): Babysitter (opiekunkę) / Nanny-Au pair (nianię lub au pair)/ Employee (nursery school) (pracownika- przedszkola,szkoły)/ Club leader (animatora)/ Trainee (if learning to be childcarer) (praktykanta)/ other (inne) (please circle and specify) (proszę zakreślić właściwe I opisać) How long have you known this person for? Jak długo zna Pani/Pan w/w osobę? What are the ages, sex and number of children the candidate looked after (Dziećmi w jakim wieku I jakiej płci opiekowała się w/w osoba): boy(s) years old, girl(s) years old How long has this person helped you? From(od) Until (do) Jak długo ta osoba pomagała Pani/Panu? Describe childcare duties in brief (proszę opisać w skrócie obowiązki w/w osoby) Did the applicant also assist with light housework? Yes No Cooking? Yes No Czy aplikantka pomagała w lekkich pracach domowych? Tak Nie w gotowaniu? Tak Nie Please consider these aspects (proszę określić poszególne cechy aplikanta) Getting along with children (kontakt z dziećmi) * Love for children (miłość do dzieci) Communication with children (porozumiewanie się z dziećmi) Understanding of children (rozumienie dzieci) Entertainment/play with children (zabawa z dziećmi) Patience (cierpliwość) Flexibility (elastyczność) Responsibility level (odpowiedzialność) Maturity level (dojrzałość) Able to follow simple instructions (zdolność do wykonywanie poleceń) Communication with adults (porozumiewanie się z dorosłymi) Overall work quality (ogólna jakość pracy) Overall attitude (ogólna postawa) *excellent- bardzo dobry; good-dobry; fair- słaby; not applicable- nie do przyjęcia Would you recommend this person to work with children?(czy poleca Pani/Pan kandydatkę do pracy z dziećmi) Yes No Any Comments? Referee s name/position* Telephone address Signature & date Speaks English: yes no By giving your reference you give permission to be contacted *family references are only valid as additional references (not part of minimum requirement)

be childcarer) (praktykanta)/ other (inne) (please circle and specify) (proszę zakreślić właściwe I opisać) How long have you known this person for? Jak długo zna Pani/Pan w/w osobę?

5 Character reference This person is applying to be an au pair in Britain (Ta osoba ubiega się o udział w programie Au Pair w Wielkiej Brytanii) Au pair name Date of Birth How long have you known the above person? (jak długo zna Pani/Pan w/w osobę?) What is your relationship with this person? (Kim Pani/Pan jest dla tej osoby?) Teacher-Tutor (nauczyciel) Employer (pracodawca) Religious leader (ksiądz/opiekun duchowy) Other - please specify Inne- proszę wymienić You must not be related (family member) to the above (osoba wydająca referencje nie może być spokrewniona z aplikantem) What do you consider his/her best qualities? Proszę wymienić najlepsze cechy charakteru aplikanta: What do you consider his/her area of weakness or something that he/she may find difficult? Proszę wymienić słabości aplikanta lub rzeczy, z którymi może sobie nie poradzić podczas pobytu w Wielkiej Brytanii? Would you recommend this person to work with children? Yes No (Czy poleciłaby Pani/Pan w/w osobę jako odpowiednią do pracy z dziećmi?) Tak Nie Please describe the applicant in your own words detailing information that may be relevant to working with children (proszę opisać cechy charaktetu aplikanta uwzględniając te, które mogą być przydatne w pracy z dziećmi) Referee s name* Speaks English yes no Telephone Daytime: Evening: Signature & date By giving your reference you give permission to be contacted *family references are only valid as additional references (not part of minimum requirement)

) Teacher-Tutor (nauczyciel) Employer (pracodawca) Religious leader (ksiądz/opiekun duchowy) Other - please specify Inne- proszę wymienić You must not be related (family member) to the above (osoba

6 Medical Questionnaire - please complete this form and also obtain a medical certificate from your doctor Au pair name Date of Birth Do you suffer from any of the following; Asthma Yes No Epilepsy Yes No Diabetes Yes No Allergies Yes No Nervous illness Yes No Stress/depression Yes No Drug problems Yes No Tuberculosis Yes No Are you taking any medication? Yes No Are you pregnant? Yes No Have you been diagnosed with HIV Or and sexually transmitted disease Yes No If yes to any of the above, please give details; Please state any other known medical conditions that should be taken into account when considering your application to become an Au Pair in the UK. Au Pair Signature: Wypełnia lekarz: Wyżej wymieniona osoba ubiega się o udział w programie Au Pair. Prosimy o odpowiedź na pytanie, zgodną z Pani/Pana najlepszą wiedzą: Would you consider this person fit to work with children? Czy stan zdrowia wyżej wymienionej osoby pozwala jej pracować z dziećmi? Yes / No Tak/ Nie Doctor s name Telephone I hereby declare that the information in this medical questionnaire is correct. Signature: Full name: Date:

Yes No Have you been diagnosed with HIV Or and sexually transmitted disease Yes No If yes to any of the above, please give details; Please state any other known medical conditions that should be

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