KES AGENCY Czech Republic

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1 KES AGENCY Czech Republic VESELI NAD MORAVOU, Chaloupky 574/17 Tel: APPLICATION FORM FOR AU PAIR NAZIONE : /COUNTRY Città/Town : Campagna/Country : Data di arrivo/arrival Ultima data di partenza: PERSONAL DETAILS: Nome /name : COGNOME/Surname : Indirizzo/Address : Telefono/ Phone : Mobil : Bigliore orario per chiamare/ Best time to call : Data di nascita/date of birth : Etå/Age : Nazionalità/Nationality : Religione : Peso e altezza/ weight/height : Passaporto, luogo del rilascio/validita : IDETAILS OF PARENTS/FAMILY: Indirizzo genitori/ Parents name and address : Tel genitori casa/parents phone, home : Tel genitori lavoro /Parents-phone at work : Professione padre e madre : Membri della famiglia, fratelli, sorelle e loro età/family members, brothers, sisters, Their ages : Tel. No/contatto di una persona in caso di emergenza/contact person in case of emergency :

2 EDUCATION AND QUALIFICATION: Il più alto livello scolastico o professionale da te raggiunto?what is the most advanced education or professional qualification that you have gained : Attuale occupazione/present occupation : Stai frequentando una scuola superiore, college o università attualmente/are you attending high school, college or university at the moment? I toui futuri progetti/your future career plans : Parli inglese/do you speak English? A che livello/what level? abbastanza buono/fair buono/good fluente/fluent Parli eltre lingue/other languages Parli la lingua della nazione dove desideri andare/do you speak the language of the country you wish to go? Numero anni studiati? Number of years studied/ Vuoi frequentare un corso di lignua/do you wish to attend language course? Dare dettagli su specializzazioni prese, corsi attinenti alla cura dei bambini/ Give details of any specialised training, talents or skills that you have, that may be useful when caring for children firs aid, life saving, childcare cours etc Hai attestati da allegare?do you have any certificates to attach? Hai già vissuto lonatno dalla tua famiglia (due mesi o più)?/have you ever lived away from home for how long? Yes Quando tornerai a casa alla fine del programma, cosa intendi fare?/when you return to your home at the end of the programme, what do you intend to do? S A L U T E / H E A L T H Hai problemi di salute?do you have any health problems /astma, epilepsy, dibetes, coldres, anorexia, bulimia, diabetes, anemia, sleep walking, heart desease, hiv infection, pregnant, hernia, ulcers, etc/? If yes, please give details : Hai allergie o paure agli animali domestici/do you have any allergies of household pets? If yes, please indicate: dog/cane cat/gatto bird/uccello other small household pets/altri piccoli animali

3 Hai allergie alimentari?/do oyu have any food allergies? Segui una dieta speciale/ Do you follow a special diet/? 46If yes, plaese indicate : vegetariana /Vegetarian other : sei stata in ospedale o sotto cura di un Medico negli ultimi 12 mesi? Have you been hospitalized or under the care of a doctor whitin the las t12 months? Hai ricevuto cure o trattamenti per problemi emotivi o nervosi, depressione o disordini alimentari?have you ever received counselling or treatment for a nervous or emotional problem, depression or an eating disorder? D R I V I N G Hai la patente di guida? Do you hold a full International driving licence? Data dell esame : Hai mai avuto incidenti/ Have you ever had a car accident? Su quale genere di strade usualmente guidi?/what kind of roads do you usually drive on? City/città highway/autostada country/campagna Qanto spesso guidi?/ How often do you drive? Sei disposta a guidare? / Do you wish to drive if a car is available? Sei disposta a guidare con bambini/do you wish to drive with the children? S M O K I N G Fumi?/Do you smoke? Quante sigarette al giorno?/how many cigarettes per day? Se fumi, ma sei d accordo di non fumare nella casa della famiglia che ti ospitera o quando sarai impegnata con i bambini, allora segna SI di seguito. Siccome ti sara richiesto di rispettare la tua decisione e importante che tu consideri bene la tua risposta. Si Non Today the vast majority of people have strong views on smoking. If you do smoke, but agree not to in the home of your host family or when responsibile for children, then tick yes below. Accetteresti una famiglia dove non è permesso fumare?/would you accept a family where smoking is not allowed? EMPLOYMENT IN THE HOST COUNTRY: Posizione richiesta /Position required : AU PAIR AU PAIR PLUS MOTHER S HELP Nazione richiesta: preferenza /Do you prefer? LARGE TOWN/grande città SMALL TOWN/piccola citta COUNTRYSIDE/campagna - 4 -

4 La prima data di arrivo/the earliest date of arrival : Periodo di permanenza/length of stay : Ultima data di ritorno/ The latest date of return : Perché vuoi essere un AU PAIR?/Why do you want to be an au pair? Quale gruppo di età preferisci?/which group of age do you prefer? New born/neo nati, 9-24 months/mesi, 2-5 years/anni, 5-10 years/anni, older than/più di 10, older than/più di 15 Preferisci una famiglia con 1,2,3, 4 bambini?/would you prefer to be placed in a family with 1, 2, 3 or 4 children? Puoi prendere in considerazione una famiglia con un bimbo con handicap? /Might you consider a family with a handicapped child if we supply details? Se si, specificare se hai avuto precedente esperienza?/if yes, specify if you have previous experience with children with special need : Potresti accettare una famiglia senza bambini? / Would you accept an adult family? Accetteresti con un singolo genitore?/would you accept a single parent? Accetteresti una famiglia con etnia e religione diversa dalla tua?/would you accept a family who is etnic and religion different from your own? Potresti preparare cibi semplici per/ Are you willing to prepare a simple meals for : Tutta la famiglia/ bambini /te stessa WHOLE FAMILY / CHILDREN/ YOURSELF Cosa sei preparata a fare tutti i lavori domestici /Are you prepared to do some housework? I tuoi hobbies /Please state your hobbies : Partecipi attivamente a qualche sport? Do you active participate any sports? Tu nuoti/ Do you swimm? Hai una formazione di musica e danza/ Do you have background in music or dance? Ti piacciono gli animali / Do you like animals? Mi piacerebbe vivere con una familgia che ha dentro casa/i am willing to live with a family who has inside the house : dog(s)/cane cat(s)/gatto bird(s)/uccello small household pet(s)/piccolo anomale domestico - 5 -

5 EMPLOYMENT RECORD: Quali esperienze hai avuto con bambini?/what experience have you got of looking after children : Sei stata già un Au Pair?/ Have you been an au pair before? Hai esperienza nei lavori domestici? What experience of light housework do you have? Sei stata mai arrestata o coinvolta in un qualsiasi reato criminale? Have you ever been arrested or convinced of any criminal offence? Data : Segnatura : KES AGENCY

6 Czech Republic VESELI NAD MORAVOU, Chaloupky 574/17 Tel: LETTERA ALLA FAMIGLIA La seguente documentazione: profilo dell'au-pair, 2 lettere di referenze, foto, certificato medico e una lettera dell'au-pair indirizzata ad una potenziale famiglia. Ostatní registrační podklady VIZ REGISTRACE angličtina

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