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HOST FAMILY APPLICATION FORM V3

Host mother

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Host father

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Address

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Family composition

Please list children of your family

First name Birth date Sex Special interests (hobbies, activities, sports, …)
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Additional information concerning your children

Do you have any disabled children or children with a handicap?
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Do your children attend school/kindergarten?
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What is the school ‘s name?
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Distance between your house and the children’s school:
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What is the kindergarten’s name?
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Distance between your house and the children’s kindergarten:
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Family / Home / Private environment

How would you describe your family? Please give yourself a score from 1 to 10

Cheerful Invalid Input Open-minded Invalid Input Respectful Invalid Input
Reliable Invalid Input Easy-going Invalid Input Warm Invalid Input
Patient Invalid Input Polite Invalid Input Talkative Invalid Input
Sociable Invalid Input Dynamic Invalid Input Perfectionist Invalid Input

Family / Home / Private environment

Give a description of your house? Invalid Input
Give description of your location? Invalid Input
Garden?
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Close to public transport?
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Close to recreation (cinema, shopping, restaurants)?
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Number of bedrooms?
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Number of bathrooms?
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Is there a cleaning lady (weekly)?
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If so, #hours/week?
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Who has taken care of the children before the arrival of your au pair?
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Did you have an au pair before?
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What is your religious affiliation?
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Do you practise your religion?
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Which languages do you speak at home?
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What other languages do you know?
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Do you have pets?
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If so, please specify?
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Do you or your family members smoke?
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Please list your family’s hobbies?
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Which big city is near your house?
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Distance between your house and closest recreation/city center?
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Information relating to your future au pair (please circle relevant answer)

You declare that you are aware that it is legally required:

- to provide a separate bedroom for your future au pair,
- to subscribe for an insurance for medical, hosiptalisation and repatriation costs, and
- to enroll your future au pair for language courses (FR, DU or GE). (*)
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Can you provide the following to your future au pair (not legally required)?

a separate bathroom
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internet access
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a separate personal computer
a car to borrow

Additional expectations concerning your future au pair?

Do you expect the au pair to be able to drive a car?
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Would you accept an au pair who smokes?
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In which language will you communicate with the au pair?
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Are there any preferential languages you want to speak with the au pair?
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Do you have any preference for any particular nationality?
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If so, specify which?
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What duties will the au pair have? (please circle relevant answer)

Childcare
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Bring children to school
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Feeding baby with bottle
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Giving bath to children
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Assisting with homework
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Babysitting during the night
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Washing clothes
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Ironing clothes
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Dusting and vacuuming
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General tidying
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Cooking
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Driving
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Shopping for food
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Take care of pets
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Other (please specify)
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Please state when the au pair can take off (besides the obligatory 1 day per week, 1 weekend per month, 1 week per 6 months)

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Do you allow your au pair to stay outside your house during weekends?
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Do you expect the au pair to travel with you?
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Costs, comments and validation

To which degree, if at all, will you reimburse the transport costs of the au pair (airplane/train ticket) form/to home/host country?
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If you do reimburse the transport costs, they can only be deducted from the monthly allowance if the au pair accepts it in writing.
You declare that you are aware that the minimum monthly allowance for the au pair is 450 €?
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Do you wish to pay the au pair more allowance?
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Your additional comments (house rules, expectations, special skills, etc)

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