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Section A : Parent’s / Family’s Details

Mrs. Mr.
Family Surname
Parents Names
ID Number
Contact Numbers
Home Number
Work Number
Fax Number
Cell Number
Email Address
Occupation
Company
Physical Address

Postal Address

Section B : Children’s Details

Name
Age
Allergies
Can they swim?
Gender
Likes

Dislikes

Physical Disabilities (if


any)
Learning Disabilities (if
any)
Personality
Section C : Au Pair Requirements

Gender
Age Preference
Religion Preference (if any)
Race Preference (if any)
Non-Smoker

Will the employee be required to travel with the family? Yes / No


Will the employee be required to work over December? Yes / No
Will the employee be required to work over Public Holidays? Yes / No

Section D : Au Pair Duties

Will the employee be required to cook meals? Yes / No


Will the employee be required to transport children around? Yes / No
Will the employee be required to supervise homework? Yes / No
Will the employee be required to bath the children? Yes / No
Will the employee be required to take the children to outings? Yes / No
Will the employee be required to attend school functions? Yes / No
Will the employee be required to run household errands? Yes / No
Will the employee be required to do grocery shopping? Yes / No
Will the employee be required to take the children for medical visits? Yes / No
Will the employee be required to wait with the children until the
parents get home from work / functions? Yes / No

Extra Notes

Working Days and Times

Day : Mon Tues Wed Thurs Fri Sat Sun


From
To
Section E : Remuneration

R ________________ gross salary per month excluding R 3 per km travelled and overtime.

The family is required to reimburse the employee at a rate of R3 per km travelled. It is recommended that
a cell phone allowance is discussed with your Au Pair in case of an emergency.

What date is your Au Pair required? _____________________________________________________

What days and times are you available to interview candidates ? ____________________________

Section F : Invoice Details

Name on Invoice
Fax Number where it can be sent or
Email Address where it can be sent
Postal Address

We confirm that we have answered all questions honestly and that all our information in our application
is true. Any other information that may be relevant to this position that has not been mentioned can be
forwarded with this document to Au Pairs@Work.

We confirm that we have read through and understood the recruitment fee schedule for Au Pairs@Work.

Au Pairs@Work cannot be held responsible for damage in the residence of the host family.

PLEASE EMAIL/FAX FORMS BACK TO ME: ilse@aupairsatwork.co.za / 086 523 1318

_____________________________ _____________________________
Host Mother Signature : Host Father Signature :

_____________________________ _____________________________

Signed at _________________ on _________________ 20 ___

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