Famille d’accueil – Au Pair Belgium

Formulaire d’inscription pour famille d’accueil

Apply here as a Host Family

Family composition

Family / Home / Private environment

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Host family information

Host Mother : First Name

Host Mother : Last Name

Host Father : First Name

Host Father : Last Name

Civil Status

Married Cohabiting Single Divorced Widowed

Host Mother : Date of Birth

Host Father : Date of Birth

Host Mother : Place of Birth

Host Father : Place of Birth

Host Mother : Nationality

Host Mother : Occupation

Host Father : Occupation

Address

Postal Code

City

Country

Host Mother : Phone

Host Father : Phone

Host Mother : Email

Host Father : Email

Host Mother : Skype ID

Host Father : Skype ID

Family description

How many children do you have ?

0 1 2 3 4 5

Name - Age

Gender

Boy Girl

Activities/Sports

Name - Age

Gender

Boy Girl

Activities/Sports

Name - Age

Gender

Boy Girl

Activities/Sports

Name - Age

Gender

Boy Girl

Activities/Sports

Is there a baby expected ?

yes no

Additional information about your children

Do you have any disabled children or children with a handicap ?

yes no

Do your children attend school/kindergarten ?

Kindergarten

School

None

What is the school's name ?

What is the school's address ?

What is the kindergarten’s name ?

What is the kindergarten's address ?

Family / Home / Private environment

Description of your home

House Apartment

Number of bedrooms

2 3 4 5

Number of bathrooms

1 2 3 4

Description of your location

Big City Small City Village

Are you close to public transportation ?

yes no

Are you close to recreation area ?

yes no

Distance between your home and closest recreation/city center

Which is the closest city near your home ?

Is there anyone for cleaning (weekly) ?

yes no

Did you have an au pair before ?

yes no

Who has taken care of the children before the arrival of your au pair ?

What is your religious affiliation ?

Do you practice your religion ?

yes no

Which languages do you speak at home ?

What other languages do you know ?

Do you have pets ?

yes no

Do you or your family members smoke ?

yes no

Please list your family’s hobbies

You declare that you are aware that it is legally required

to provide a separate bedroom for your future au pair

yes no

to subscribe for an insurance for medical, hosiptalisation and repatriation costs

yes no

to enroll your future au pair for language courses (FR - NL - GE)

yes no

Can you provide the following to your future au pair (not legally required) ?

a separate bathroom

yes no

internet access

yes no

a separate personal computer

yes no

a car to borrow

yes no

Additional expectations concerning your future au pair

Do you expect the au pair to be able to drive a car ?

yes no

Would you accept an au pair who smokes ?

yes no

Do you have any preference for any particular nationality ?

yes no

In which language will you communicate with the au pair ?

Are there any preferential languages you want to speak with the au pair ?

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)

Whole weekend Saturday only Sunday only Weekday

Would you allow your au pair to stay outside your house during weekends ?

yes no

Do you expect the au pair to travel with you ?

yes no

What duties will the au pair have in charge ?

Newborn care

yes no sometimes

Feeding baby

yes no sometimes

Childcare

yes no sometimes

General tidying

yes no sometimes

Assisting with homework

yes no sometimes

Washing clothes

yes no sometimes

Dusting and vacuuming

yes no sometimes

Cooking

yes no sometimes

Shopping for food

yes no sometimes

Bring children to school

yes no sometimes

Bathing children

yes no sometimes

General tidying

yes no sometimes

Babysitting

yes no sometimes

Ironing clothes

yes no sometimes

Taking care of pets

yes no sometimes

Other ( please specify )

What type of au pair would suit your family ?

Relevant answers

Flexible

Motivated

Co-operative

Sensitive

Sociable

Firm

Independent

Responsible

Hygienic/tidy

Common sense

Educative

Initiative

Costs - Comments - Validation

You declare that you are aware that the minimum monthly allowance for the au pair is 450 € in Belgium

yes

Do you wish to pay the au pair more allowance ?

yes no

Reimburse ratio %

To which degree, if at all, will you reimburse the transport costs of the au pair (airplane/train ticket) form/to home/host country. If you do reimburse the transport costs, they can only be deducted from the monthly allowance if the au pair accepts it in writing.

Not at All 30% 40% 50% 100%

Your additional comments (house rules, expectations, special skills, etc)

We declare that the information provided in this application form is true and correct. We also agree that any uncorrect or false answer may lead to a cancellation of the Au Pair Program and will allow the au pair to leave our family and ask reimbursement of all costs made by him/her in respect of his/her placement as an au pair in our family and that we will comply with the legal provisions regarding au pairs in Belgium

Yes, information provided in this application form is true and correct.