Registration for Au Pairs - Heavenly Au Pairs

I am *

Male
Female

Surname/Family Name *

First Name *

Email Address *

House/Flat Number *

Street *

Town/City *

State/Region/Province *

Post Code (Zip Code) *

Country *

Telephone Number *

(including dailing codes)

Mobile (Cell) Phone number *

(if you do not have one write 'None')

Skype Address *

(if you cannot set up a skype account
then please write 'none')

What is your date of birth? *

/ /

What is your current age? *

What is your main Nationality? *

Do you have another Nationality?

Where do you live at the moment? *

What is your Marital Status? *

Do you have a steady boyfriend/girlfriend?

Yes
No

If Yes, do you live together?

Do you have any children of your own? *

Yes
No

Do you need any special diet? *

If Other, please explain

What is/was the occupation of your mother? *

What is/was the occupation of your father? *

Do you have any brothers or sisters?
Please provide details of their age, their occupation and if they live with you.
If you are a single child, please write 'single child'.

Have you worked as an Au Pair before?

Yes
No

Do you have childcare experience? *

Yes
No

Please list your childcare experience, describing
responsibilities and stating period of time worked
(with approximate dates)

Have you lived away from home before?

Yes
No

If yes, please explain

Do you have a full driving license? *

Yes
No

If Yes, what date did you pass your driving test?

/

Are you willing to drive in your destination country? *
(after extra lessons/time to practise)

Yes
No
Not sure

Do you smoke? *

Yes
No
Socially

Do you mind if one of the hosts smokes?

Yes
No

Do you drink alcohol? How often?

Do you have any medical condition- whether or
not it affects your ability to be an Au Pair? *

Yes
No

If yes, please explain

Do you have any allergies? *

Yes
No

If yes, please explain

What is your Native language/Mother tongue? *

Other languages you have Good knowledge of:

Other languages you have Basic knowledge of:

How well do you speak the language of your destination country? *

Are you applying to be an au pair in the UK? *

Yes
No

If no, please tell us where you would like to be an Au Pair:

Destination Choice 1

Destination Choice 2

You accept being placed in:

city
town
village
rural location

Please mark all that apply

Is there a specific region/ town where
you would prefer to live?

Are you willing to help with household chores? *

Yes
No

Do you have experience with household chores? *

Yes a lot
Adequate experience
Not very much

Are you happy to join a single parent family?

Where the dad is single parent?

Yes
No

Where the mum is a single parent?

Yes
No

Are you happy to look after disabled children?

What is the preferred age of the children
you would look after?

Do you have a valid passport for travel to
and being an au pair in your destination country? *

Yes
No
Not sure

Do you need a visa to be an Au Pair in your
destination country? *

Yes
No
Not sure

If Yes, do you already have your visa and
when does it expire?

Do you have a criminal record? *

Yes
No

If yes please explain

Can you provide a very recent Police Check? *

Yes
No

Can you provide a very recent Medical Certificate? *

Yes
No

If yes please explain

Please indicate if you have ever suffered
from any of the following: *

Do you take medication? (apart from contraceptive pill) *

Yes
No

If yes please explain

Have you ever had an operation?

Yes
No

If yes please explain and give dates

Earliest date you can start with family *

/ /

Latest date you can stay with family until *

/ /

How many months would you ideally like to stay?

Do you have references available for: *

Your Childcare experience/work
Education(school, university, diploma)
From a previous job/employer
Character reference (not by friend or family)
Other (certificates)

If no, can you get references?

What qualification, if any, do you have?
Or will you have before you start as Au Pair?
Please explain

(A levels, University degree, childcare qualifications etc.)

Which 5 words MOST accurately describes you?

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