Aplikacja UK

Application Form for Au Pair/ Mother’s Help
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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
Address
Contact details
Nationality
Phone:
Country currently living in:
Age and date of birth
E-mail:
Skype Address:
Date of Birth
Nationality and
Passport number
Marital status:
Nationality
Passport number
Married Single Boyfriend/Girlfriend Divorced
What type of location
do you currently live in?
City
Mobile:
Fax:
Age
Town Village Countryside
General questions
Do you drive?
Do you smoke
Available from-until
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
Yes
No
If yes, will you agree to not smoke in the house or around the kids? Yes
From:
Until:
The longer you can stay the better it is
Where do you wish to
work? Please X all that
FLEXIBLE
apply
Specific location:
Au-pair
Au-pair +
Positions Sought
City
Town
Village
UK Countryside
Scotland
No
Ireland
Mothers help, only if you have 1 year + experience with children
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?
Au Pair, 20-25 hours, 2 free days and (up to) 2 nights babysitting, pocket money from £70
Au Pair plus, 30-35 hours, 2 free days and (up to) 3 nights babysitting, pocket money from £80
Mother’s help, 35-45 hours per week with at least 1 day off – £100 - £200+
1.Name and age:
2.Name and age:
3.Name and age:
4.Name and age:
Do you wish to attend
English classes?
FLEXIBLE
Do you like pets?
Yes
No
Care for pets?
Yes
No
Poor
Adequate
Yes
Good
Very good
No
Are you in perfect
health? Allergies etc.
Please give details.
Specific food
requirements?
(Vegetarian etc)
Please give details.
Can you swim?
Yes
No
Yes
No
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
Yes
No
X as many as apply. The
more you tick the more
choice of family you’ll get
FLEXIBLE
Yes
FLEXIBLE
Yes
Cook
Supervise homework
Wash up after meals
Help with shopping
No
Yes, if they speak English at home
No
Single mother only
Tidy/Clean children’s rooms Hoover
Supervise bedtime
Baby-sit
Wash Children’s clothes
Iron
Tidy/dust
Please tell us briefly
about your hobbies
and interests:
Please state what
qualities you find most
important in yourself.
( Ex. Reliable, flexible etc)
Education and qualifications
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.
Childcare Experience
Are you experienced
with the following?
Please give brief
details of your current
childcare experience,
including babysitting,
summer camp. Ages
of children etc.
What age of children
do you prefer?
Babies under 6 months Yes No Happy to learn
Toddlers
Yes No Happy to learn
School aged children? Yes No Happy to learn
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.39
25-019 Kielce
email: [email protected]
tel. 041 345 34 20
www.kangiel.pl,
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
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)
How long has this person helped you?
years old
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?
Nie
Please consider these aspects (proszę określić poszególne cechy aplikanta)
Getting along with children (kontakt z dziećmi)
Excellent
Love for children (miłość do dzieci)
Excellent
Communication with children (porozumiewanie się z dziećmi)
Excellent
Understanding of children (rozumienie dzieci)
Excellent
Entertainment/play with children (zabawa z dziećmi)
Excellent
Patience (cierpliwość)
Excellent
Flexibility (elastyczność)
Excellent
Responsibility level (odpowiedzialność)
Excellent
Maturity level (dojrzałość)
Excellent
Able to follow simple instructions (zdolność do wykonywanie poleceń)
Excellent
Communication with adults (porozumiewanie się z dorosłymi)
Excellent
Overall work quality (ogólna jakość pracy)
Excellent
Overall attitude (ogólna postawa)
Excellent
Good
Good
Good
Good
Good
Good
Good
Good
Good
Good
Good
Good
Good
Tak
Fair
Fair
Fair
Fair
Fair
Fair
Fair
Fair
Fair
Fair
Fair
Fair
Fair
Not Applicable*
Not Applicable
Not Applicable
Not Applicable
Not Applicable
Not Applicable
Not Applicable
Not Applicable
Not Applicable
Not Applicable
Not Applicable
Not Applicable
Not Applicable
*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)
Any Comments?
Yes
No
Referee’s name/position*
Speaks English: yes
Address
Telephone
E-mail address
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)
no
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?
(Czy poleciłaby Pani/Pan w/w osobę jako odpowiednią do pracy z dziećmi?)
Yes
No
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
Address
Telephone
Daytime:
Evening:
E-Mail Address
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)
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
Address
Telephone
I hereby declare that the information in this medical questionnaire is correct.
Signature:
Full name:
Date: