Surname:

First name(s):

Date of Birth:

Nationality:

Country of Birth:

Height:

Weight:

Occupation:

What is you current salary?

(per year) or
(per week)

Religion:

Practising

Address:

Postcode:

Phone (Home):

Phone (Work):

Phone (Mobile):

Fax:

E-mail:

Passport Number:

Expiry Date:

Family Details

Marital Status:

Do you have dependents?

If yes, please state their ages:

Maximum Period Available

Start Date:

Length of Stay:

Country / City Required (state preference)

1

2

3

Position Sought & Expected Pay

Nanny Mother's Help Housekeeper Holiday Nanny Other (specify)

If other please specify:

I prefer to:

What salary are you seeking?

(per year) or
(per week)

Preferences

I would prefer to work with children aged (you can select more than one):

I would like to look after (you can select more than one):

I am willing to work with (you can select more than one):

I am willing to do (you can select more than one):

Education/Qualifications

Please list childcare qualifications:

Do you have any experiences with babies and children in the following age ranges (you can select more than one)?

Will you provide references for these?

No Yes

Do you have knowledge of First Aid?

Knowledge of Languages

Native Language

Other Languages

Employment History

Please describe your last two childcare positions - including duties, approximate working hours, length of employment and reason for leaving:

Position 1:

Referee:

Phone:

Position 2:

Referee:

Phone:

My experience of housework covers:

I am willing to do light housework besides housework for children:

Hobbies & Interests

My special hobbies and interests are (if you participate in sports, please list them):

Can you swim?

Driving

Do you have a full driving licence?

Date of Issue

Would you drive during your stay?

Any endorsements?

Do you have any penalty points?

If yes, for what offence:

Have you ever been banned from driving?

If yes, please state date and the reason:

Do you own a car?

If no, do you have access to a car?

Smoking, Drinking, Drugs & Health

Do you smoke?

If yes, how many per day?

If yes, are you prepared not to smoke in your employer's house?

Do you take drugs/medication (you can select more than one):

Do you suffer from any mental or physical health problems?

If yes, please give details:

Are you a vegetarian?

Have you got any special diets?

If yes, please give details:

Do you drink alcohol?

Are you allergic to any of the following (you can select more than one)?

If you selected any of the above, please give details:

Criminal Convications

Have you ever been convicted of a criminal offence??

If yes, please give details:

Mother's Help Agreement

Please read the following and then sign.

Mother's Help Agreement: I certify that the above information is truthful and accurate to the best of my knowledge and I agree that my details will be sent to potential employers. I agree to inform Sunflower Au-Pair & Mothers Help Agency immediately if I am offered a position by a Third Party (relative/friend of an Sunflower Au-Pair & Mothers Help Agency client).

I, (please state your full name), have read, understood and accepted the above "Mother's Help Agreement": (please tick)

"Submission of your Mother's Help application form to Sunflower Au-Pair & Mothers Help Agency constitutes acceptance of the above Mother's Help Agreement".