0208 8888144 / 01279 792222 wellfield.international office@wellfieldinternational.co.uk
PERSONAL INFORMATION
Parent 1
Full name
Home address
Post code
Home phone
Work phone
Mobile phone
Email address
Occupation / Title
Employer
Work address
Does your job regularly take you out of the home in the evening

YesNo

Nationality
Main language at home
Religion / Practising
Birthday (DD/MM/YYYY)
Parent 2
Full name
Home address
Post code
Home phone
Work Phone
Mobile phone
Email address
Occupation / Title
Employer
Work address
Does your job regularly take you out of the home in the evening

YesNo

Nationality
Main language at home
Religion / Practising
Birthday (DD/MM/YYYY)
EMERGENCY CONTACT
please detail another person that may be contacted if both parents are unreachable
Name
Address
Telephone Numbers
Relationship to child / children
CHILDREN
First Child
Name
Birthday (DD/MM/YYYY)
Gender

BoyGirl

School / Nursery hours
Special care

YesNo

Second Child
Name
Birthday (DD/MM/YYYY)
Gender

BoyGirl

School / Nursery hours
Special care

YesNo

Third Child
Name
Birthday (DD/MM/YYYY)
Gender

BoyGirl

School / Nursery hours
Special care

YesNo

Fourth Child
Name
Birthday (DD/MM/YYYY)
Gender

BoyGirl

School / Nursery hours
Special care

YesNo

Fifth Child
Name
Birthday (DD/MM/YYYY)
Gender

BoyGirl

School / Nursery hours
Special care

YesNo

Your form question
Are you currently expecting a baby/babies or planning to adopt a child under the age of two?

YesNoN/A

If Yes, please give details
Do any of your children have a medical condition your candidate needs to be aware of?
INTERESTS
Please indicate what interests or abilities the members of your family have

SwimmingHorse RidingCyclingSkiingTennisRunningSoccerGymReadingWritingArts / CraftsHistoryMusicTheatreCinemaMoviesMuseumsTravellingSocialisingTrips / ToursDanceParksEating outPhotographyPicnicsVolunteeringCookingBakingFast foodComputers

Other (please specify)
FAMILY AND HOME
Are there any smokers in the household

YesNo

Any specific dietary restrictions (e.g Vegetarian)
Family religious or cultural practices
Other persons living in the house
Details of any pets
If you have pets do you want them to be cared for

YesNoN/A

Have you ever had residential help before

YesNo

Was it a good experience

Yes CompletelyYes quite goodNot greatNovery badN/A

Other domestic help employed? e.g. cleaner / gardener / housekeeper and their frequency
Wifi access available

YesNo

Please describe your family home (number of bedrooms, bathrooms, garden etc.)
Description of candidates room
Local amenities / recreational activities
Nearest bus stop
Nearest train / tube station
PERSONAL SPECIFICATION
Preferred Nationality
Preferred Age Range
Level of English* (Basic, Pre-Intermediate, Intermediate, Advanced, Native
Driver required

YesNo

Smoker accepted

YesNo

Gender preference

MaleFemaleNo preferences

Personality type
JOB SPECIFICATION
Start time
Finish time
Total hours per week
Weekly pay
Working days

MondayTuesdayWednesdayThursdayFridaySaturdaySunday

Babysitting required for

MondayTuesdayWednesdayThursdayFridaySaturdaySunday

Level of Childcare (low, medium, high)
Level of Housekeeping (low, medium, high)*
Free time
Other perks
Please indicate what type of candidate are you looking for?

Au Pair (18-30 years)Au Pair Plus (18-30 years)Mother’s help (23-55 years)Nanny (23- 55 years)Manny (23- 55 years)

Please indicate the job status of your candidate:

Full time /live inFull time /live outPart time /live inPart time /live out

Please indicate the length of stay of your candidate:

3 months6 months12 months24 months

Weekly work schedule
Any other details that will help us to select the right candidates for you
BENEFITS
Please indicate if you are:

Deducting and paying the employee’s Income Tax and National Insurance contributionsPaying Statutory benefitsMaternity PaySick PayRedundancy PayWorkplace PensionPaid Holidays
*Please fill out the boxes if you have opted any of the following domestic helpers: mother’s help, nanny, manny.
*Please note that au pairs are not usually considered workers or employees, therefore this section is optional.
*Please note as an employer you have certain responsibilities, like meeting the employee’s rights and deducting the right taxes.
*Please note our candidates are preferring families who would meet their legal rights.

AFTERCARE
How did you hear about our agency
Please upload a family photo so that your candidate can familiarise herself with you before the interview
I confirm that I haven't given any false or misleading information on my application form and I shall notify the agency immediately in writing if there are any changes to the information given above I understand that Wellfield International Placement Agency Ltd cannot be held responsible for any action of applicants engaged through the agency. I have received and agree to the Terms & Conditions of business & the scale of charges within them. It is my understanding that the agency charges an annual renewal fee and if I refer any clients to the agency upon completion of their file I shall receive a $100 credit on my file *

Yes