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 Basic/BegginerPre-IntermediateIntermediateAdvancedNativen/a Basic/BegginerPre-IntermediateIntermediateAdvancedNativen/a Basic/BegginerPre-IntermediateIntermediateAdvancedNativen/a 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 1. 2. 3. 4.