0208 8888144 / 01279 792222 wellfield.international office@wellfieldinternational.co.uk
Personal Infomation
Full name
Post code
Home address
Home Phone
Mobile phone
Email address
SKYPE ID
Occupation/ Title
Nationality
Religion / Practising
Passport number
When would you be able to start?
How long do you plan to stay?
EMERGENCY CONTACT
Name
Address
Telephone Numbers
Relationship to candidate
EDUCATION AND QUALIFICATIONS
Please Detail Any Relevant Qualifications You Have Achieved
Name of School/ Course Duration Examinations passed Other comments
1.
2.
3.
INTERESTS
Please indicate what interests or abilities you have

SwimmingSoccerMusicSocialisingPicnicsHorse RidingGymTheatreTrips / toursVolunteeringCyclingReadingCinemaDanceCookingSkiingWritingMoviesParksBakingTennisArts / craftsMuseumsEating outFast foodRunningHistoryTravellingPhotographyComputers

Other (please specify)
HEALTH STATUS
Are you in good health?

YesNo

If no, please give details
Do you smoke?
How many cigarettes a day?
Can you restrain yourself while in the vicinity of children?

YesNoN/A

Do you have any allergies to food, animals, etc?
Do you keep any diet or have any food restrictions
PERSONAL SPECIFICATION
Languages spoken and level

How would you describe yourself?
Musical Ability
Do you have a driving licence?

YesNo

Are you a confident driver?

YesNo

Do you accept to drive for the host family?

YesNo

Can you cook?

YesVery wellQuite wellNot very wellNoNot at all

List some dishes you like to cook
GENERAL INFORMATION
Experience with children

0-12 months12-24 months2-4 years4-6 years6+ years

Willing to work with children

0-12 months12-24 months2-4 years4-6 years6+ years

Do you have experience with Physically or mentally disabled children?

YesNo

Do you accept to look after children that are physically or mentally disabled?

YesNo

Please indicate the childcare duties you are willing to undertake/assist

Prepare formulaReadingHelp getting dressedFeed babyWritingOutingsChange nappiesWalk child to schoolPotty trainingChild’s laundryDrive child to schoolPrepare mealBed timeArts & CraftsBath time

Please indicate the household duties you are willing to undertake/assist

DustingClearing tableHooveringSetting tableWashing dishesSweepingWashing laundryMaking bedsIroningGardeningCookingFeeding pets

PREFERENCES
Would you accept families of a different ethnic background?

YesNo

Do you accept a family in:

LondonBig citySmall cityCountryside

How many children would you accept in the Host family?

1-22-33-45

EXPERIENCE IN CHILDCARE
Please indicate what type of childcare experience you have

Siblings / FamilyDay-careOutside organizationsBabysittingAu Pair

Please indicate the specialized skills you have which would be useful when responsible for children

First Aid / LifesavingNurse’s trainingLife-guardingNewborn classesChild development classesN/A

Please write your Personal Statement (Dear Family letter) here. This should be something you want to tell the family about yourself. It can be as long or short as you like…
Please send this form together with
-Dear family letter
-Police check or CRB
-Medical check
-2 childcare references
-Photos
-Passport/ID Copy
-Driving license Copy if you have one
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