CONSTITUTION DU DOSSIER

Medical Form Part A

Medical Form Part B

CONSTITUTION DU DOSSIER

Childcare Experience Form Membership Number:

Document Metadata

Table of Contents

Document Metadata

FICHE D’’’INSCRIPTION AUSTRALIE

AIFS AU PAIR CHILDCARE REFERENCE

Nous adresser :

1. L’Application Form, complétée à l’encre noire, et en anglais. Merci d’écrire le plus lisiblement possible.

2. 2 photos d’identité souriantes (écrire votre nom au dos) + un minimum de 4 photos de vous avec des enfants, en famille, entre amis, à coller sur une feuille de papier (Canson couleur par exemple) et à assortir d’une petite légende en anglais. N’hésitez pas à faire preuve de créativité dans la mise en page.

3. Une lettre de présentation, très détaillée, en anglais. Précisez vos motivations, vos expériences de garde d’enfants, votre personnalité, vos loisirs, pourquoi vous avez choisi ce pays…

4. La Childcare Experience Form rempli, récapitulant vos expériences de gardes d’enfants.

5. Au minimum 2 références de garde d’enfants détaillées (utiliser le formulaire « Childcare Reference » contenu dans la brochure) rempli par les signataires. Joignez une traduction (simple), si le signataire a rempli la fiche en français.

6. Le Medical Form rempli par vous et votre médecin.

7. Un extrait de casier judiciaire. En faire la demande par Internet, xxx.xxx.xxxxxxx.xxxx.xx/x0/

8. Au minimum 2 références de moralité d’un professeur, d’un employeur ou de quelqu’un qui vous connaît bien (utiliser le formulaire « Character Reference »). Vous joindrez une traduction simple, si le signataire a rempli la fiche en français.

9. L’accord I.A.P.A signé (après l’avoir lu attentivement).

10. Le document AIFS Au Pair in Australia Agreement concernant l’assurance, rempli et signé.

11. Photocopie de votre dernier diplôme obtenu, passeport et permis de conduire.

12. Vidéo de présentation d’une à deux minutes (en anglais) à nous envoyer par email : xxxxxxxxxxxxxxxx@xxxxxxx.xx ou le lien pour la visionner.

13. Les frais d’adhésion et de cotisation à l’association : 90 euros d’adhésion, 350 euros de cotisation

A NOTER : Nous vous demandons de nous faire parvenir deux chèques, l’un de 90 Euros qui correspond aux frais d’adhésion, non remboursable, et encaissé lors du dépôt de votre dossier, l’autre de 350 Euros qui sera encaissé lors de votre placement dans la famille d’accueil. En cas d’annulation de votre part, les frais d’adhésion et de cotisation (440 euros) resteront acquis à l’agence et ne seront pas remboursés. Merci d’avance.

N’OUBLIEZ PAS QUE DE LA QUALITE DE VOTRE DOSSIER VA DEPENDRE L’EFFICACITE DE VOTRE PLACEMENT !

Si vous en possédez, n’hésitez pas à ajouter des photocopies de BAFA, etc.… Merci de ne pas nous adresser de dossiers incomplets ou ne répondant pas aux conditions énumérées ci-dessus. Ne procédez à aucune réservation de transport et ne partez pas avant d’avoir reçu l’accord explicite de la famille d’accueil, votre offre de placement et les coordonnées de votre bureau correspondant.

00, xxx xx Xxxx 00000 Xxxxx – Xxxxx Xxxxx. Tél. 00 00 00 00 00 – Fax 00 00 00 00 00 E mail : xxxxxxxxxxxxxxxx@xxxxxxx.xx Site web : xxx.xxxxxxxxxxxxxxxx.xxx Association régie par la loi 1901

Photo

APPLICATION FORM

DISPONIBILITE – AVAILABILITY

A quelle date pourriez-vous arriver au plus tôt ? Earliest date you could arrive ?

A quelle date pourriez-vous arriver au plus tard ? Latest date you could arrive ?

DETAILS PERSONNELS – PERSONNAL DETAILS

Nom de famille Surname	Prénom First Name
Date et lieu de naissance date and place of birth		Age
Nationalité Nationality	Votre profession your occupation
N° de Tel. phone #	N° de mobile mobile #
N° de Tel. de vos parents : parents phone :
E mail	Passeport n°
Adresse address (indiquez celle où l’on pourra à nouveau vous écrire à votre retour)
Ville City	Code Postal Zip code
Profession du père profession of the father Profession de la mère profession of the mother
Age des frères et sœurs age of brothers and sisters

EDUCATION

Connaissances linguistiques : language knowledge						Combien d’années avez-vous étudié cette langue ? how many years have you studied this language ?
	Excellente Excellent	Bonne upper- intermediate	Moyenne intermediate	Passable pre- intermediate	Faible poor
Anglais English	❑	❑	❑	❑	❑
Espagnol Spanish	❑	❑	❑	❑	❑
Allemand German	❑	❑	❑	❑	❑
Autres Others	❑	❑	❑	❑	❑
Diplômes obtenus et dates ? degrees and dates

EXPERIENCE
Vous êtes-vous déjà occupé de bébés ? Have you ever be in charge of a baby ? ❑ YES ❑ NO Accepteriez-vous de vous occuper d’un bébé ? Would you accept to take care of baby ? ❑ YES ❑ NO
		Expérience	Préférence
9 mois – 2 ans : 9 months – 2 years 2 ans – 6 ans : 2 years – 6 years 6 ans – 10 ans : 6 years – 10 years + de 10 ans : more than 10 years enfants handicapés : children with disabilities :		❑ ❑ ❑ ❑ ❑	❑ ❑ ❑ ❑ ❑
Avez-vous déjà été au pair ? Have you ever been au pair ? ❑ YES ❑ NO Où et quand ? Where and when ?
Avez-vous des diplômes de garde d’enfants, lesquels ? Do you have any chidcare diploma ? Avez-vous un brevet de premiers secours ? Do you have a first aid diploma ? ❑ YES ❑ NO
Quelles activités ménagères vous sont familières ? What experience do you have with domestic work ?
Cuisine cooking ❑	Rangements cleaning up ❑	Laver le linge laundry ❑
Repassage ironing ❑	Aspirateur vacuuming ❑	Laver la vaiselle dishes ❑
DIVERS – MISCEALLANEOUS.
Accepteriez-vous de vivre avec une famille monoparentale ? Would you accept to live with a single parent ? ❑ YES ❑ NO
Avez-vous le permis de conduire ? Do you have your driving licence ? ❑ YES ❑ NO Date d’obtention Since when ?
Fumez-vous ? Do you smoke ? ❑ YES ❑ NO Combien de cigarettes par jour ? How many cigarettes a day ?
Souffrez-vous d’allergie(s), laquelle ? Do you suffer from any allergy, which one ? Souffrez-vous d’une maladie chronique, laquelle ? Do you suffer from any chronic illness, which one ?
Comment nous avez-vous connus ? How did you get to know us ?

Les frais d’adhésion et de cotisation sont à régler à l’inscription avec le dossier complet. En cas de non-placement, et dans ce cas seulement, les frais de cotisation seront intégralement remboursés.

Les frais d’assurance sont à régler à confirmation de placement.

Frais d’adhésion : 90 euros Frais de cotisation : 350 euros

Frais d’assurance : A$595 pour 7 mois Formation au secourisme : A$50

Working With Children Check : A$80 à régler durant l’orientation

IMPORTANT :

Europair Services ne peut en aucun cas être tenu pour responsable des accidents, pertes, dommages, plaintes ou dépenses particulières en relation avec le séjour de l’au pair en famille.

En cas de non placement de la candidate par l’agence AIFS, Europair Services décline toute responsabilité de ce non placement.

Je m’engage à respecter ces conditions, et certifie que les renseignements ci-dessus sont exacts.

Xx et approuvé Date : Signature

ACCORD AU PAIR

International Au Pair Association

Je soussignée ....................................................................................................... certifie avoir pris connaissance de tous les documents fournis par l’association EUROPAIR SERVICES et remplir tous les critères exigés.

J’ai bien compris que le programme au pair est un échange culturel et non un contrat de travail, qu’être au pair demande un niveau élevé de responsabilité et de flexibilité et enfin que je devrai m’acquitter des tâches demandées par la famille d’accueil du mieux possible.

Je certifie que j’ai répondu à toutes les questions en toute honnêteté et que toutes les informations fournies dans mon dossier sont vraies.

Après confirmation de mon placement je m’engage à rester en contact a avec ma famille d’accueil et à la tenir informée des modalités de mon voyage.

Je m’engage à m’occuper, le cas échéant, de toutes les démarches nécessaires à l’obtention d’un passeport et d’un visa.

Sauf si spécifié autrement dans le texte du programme je m’engage à régler tous les frais relatifs à un cours de langue, à mes trajets aller et retour, à mes frais de téléphone et à me munir de suffisamment d’argent de poche pour régler les frais imprévus.

Je connais toutes les conditions du programme au pair et m’engage à les respecter, particulièrement en ce qui concerne le nombre d’heures de travail et leur répartition, les tâches à effectuer, l’argent de poche, le temps libre, les vacances, les cours de langue, les frais de transport et les assurances.

Une fois dans le pays d’accueil je me mettrai d’accord avec ma famille sur les tâches que j’aurai à effectuer, mes droits et ceux de ma famille.

Je m’engage à assumer mes responsabilités vis-à-vis des enfants de ma famille d’accueil, à assurer les tâches ménagères courantes qui me seront demandées et à tenir ma chambre propre et en ordre.

Je m’engage à me conduire correctement au sein de ma famille d’accueil et à respecter leurs règles de vie notamment en ce qui concerne l’usage du téléphone et autres facilités de la maison, les visites d’amis et les sorties nocturnes, l’interdiction éventuelle de fumer.

Je m’engage à faire les efforts nécessaires pour m’intégrer à la vie familiale, à discuter ouvertement des problèmes éventuels afin de trouver ensemble une solution équitable, à prendre l’avis des parents au sujet de la discipline à imposer les enfants. Je comprends que je ne dois jamais laisser les enfants seuls lorsqu’ils sont sous ma responsabilité et que je ne dois ni les punir, ni les battre.

Je m’engage à régler avec ma famille d’accueil toutes les modalités de mes vacances bien avant de les prendre.

Je m’engage à faire les efforts nécessaires pour connaître la culture du pays d’accueil et pour en apprendre la langue, à respecter les différences et à me montrer tolérante.

J’ai parfaitement compris que le succès de mon séjour au pair dépendra pour une grande partie de mon attitude et de ma participation. Toutefois en cas de problème insoluble avec ma famille d’accueil je m’engage à prendre contact sans tarder avec le bureau correspondant de l’association EUROPAIR SERVICES dans le pays d’accueil, pour assistance.

Si aucune solution n’est trouvée et que je décide de quitter ma famille d’accueil je m’engage à lui donner un préavis de 2 semaines. Pendant cette période je m’engage à continuer d’exécuter mes tâches correctement. En contrepartie je continuerai à recevoir mon argent de poche, à être nourrie et logée.

Tout manquement de ma part peut provoquer mon renvoi, notamment en cas de :

• non-respect des règles du programme au pair

• non-respect des règles de vie de la famille

• communication d’informations erronées dans mon dossier d’inscription

• début du séjour sans confirmation officielle de placement par l’organisme dans mon pays d’origine ou sans visa en règle (le cas échéant)

• responsabilité reconnue de problèmes avec la famille d’accueil

• non-respect des lois du pays d’accueil.

Je m’engage à n’accepter aucun emploi rémunéré en dehors de ma fonction de stagiaire au pair. Le cas échéant j’accepte de quitter le pays d’accueil avant expiration de mon visa.

Je m’engage à informer l’association EUROPAIR SERVICES de tout changement relatif aux informations fournies dans mon dossier.

DATE : ............................................................................. SIGNATURE :

00, xxx xx Xxxx 00000 Xxxxx – Xxxxx Xxxxx. Tél. 00 00 00 00 00 – Fax 00 00 00 00 00 E mail : xxxxxxxxxxxxxxxx@xxxxxxx.xx Site web : xxx.xxxxxxxxxxxxxxxx.xxx Association régie par la loi 1901

AIFS Au Pair Application Form

Personal Details

Last Name as it appears in the passport First Name

Street, No. Postal code City Country Telephone (country code – city code – number) Best time to call ❑ mobile Alternative phone Best time to call ❑ mobile Email Date of Birth (day.month.year) age City of Birth Country of Birth Country passport issued in Passport number Passport expiry date

Current Occupation: previous occupation, if unemployed:

Emergency Contact

Last Name First Name Does this person speak English? ❑ Yes ❑ No

Relationship to participant

Country Phone number (country code – city code – number) E-mail

Availability

Preferred departure date (month / year):

Alternative Departure Dates (months / year): Date away (e.g. vacation) if known:

Experience & Preference

Please tick all appropriate boxes

Experience with this group Willing to care for this group

3 months – 1 year ❑ ❑

1 – 2 years ❑ ❑

2 – 6 years ❑ ❑

6+ years ❑ ❑

Children with disabilities ❑ ❑

2 or more children at the same time ❑ ❑

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AIFS Au Pair Application Form

Family Background

What is your religion? Do you regularly attend religious services? ❑ Yes ❑ No What is your native language? Do you speak any other languages? ❑ Yes ❑ No If yes, please list How many brothers and sisters do you have?

Have you ever lived away from home? ❑ Yes ❑ No If yes, how long?

Driving Experience

Do you hold a FULL driving license (Including practical & theory tests)? ❑ Yes ❑ No

Date passed: Have you ever had a car accident? ❑Yes ❑ No If yes, please give details How often do you drive? ❑ Every day ❑ 3-5 times/week ❑ 1-2 times/week ❑ less than once a week In your home country, what kind of roads do you usually drive on?

❑ City ❑ Suburban ❑ Highway ❑ Country

Hobbies and Interests

Please check x your hobbies and interests:

❑ Swimming ❑ Riding ❑ Cycling ❑ Skiing ❑ Tennis ❑ Soccer ❑ Running

❑ Gymnastics ❑ Community service ❑ Cooking ❑ Photography ❑ Writing

❑ Computers ❑ Reading ❑ Craft ❑ Internet ❑ Choir ❑ Dance

❑ Other hobbies:

❑ Musical instruments: ❑ Piano ❑ Violin ❑ Flute ❑ Guitar

❑ Other instrument:

Do you know how to swim? ❑ Yes ❑ No If yes, how well? ❑ Beginner ❑ Intermediate ❑ Advanced Would you feel comfortable guarding children while they are swimming ❑ Yes ❑ No

What are your favourite things to do in your spare time?

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AIFS Au Pair Application Form

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AIFS Au Pair Application Form

General Health and Criminal Information

Information about smoking

Do you smoke cigarettes? ❑Yes ❑ No If yes, do you smoke ❑ Regularly ❑ Socially

How many cigarettes do you smoke per day? NO SMOKING DECLARATION: Read this if you answered YES to the question above. If you do smoke, but agree not to in the home of your host family or when responsible for the children, then tick YES below.

You will be expected to abide by your decision so consider it carefully. ❑ Yes ❑ No

Information on criminal record

Have you ever been convicted of or charged with a criminal offence? ❑ Yes ❑ No

If yes, give details:

Health Information

Have you ever been a victim of sexual, emotional or physical abuse ❑ Yes ❑ No If yes, give details

Do you have any chronic or reoccurring health problems e.g. asthma, diabetes, epilepsy, cold sores ,

❑ Yes ❑ No If yes, give details

Do you have any allergies? ❑ Yes ❑ No If yes, please specify:

Do you follow a special diet? ❑ Yes ❑ No If yes please indicate: ❑ Vegetarian ❑ Kosher ❑ Other Comments: Have you ever been hospitalized or under the care of a doctor within the last 12 months ❑ Yes ❑ No

If yes, give details

Have you ever suffered from or received counselling or treatment for a nervous or emotional problem, e.g. any kind of depression, anxiety or eating disorder? ❑ Yes ❑ No If yes, give details

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Documented Childcare Experience What kind of childcare experience have you gained within the last 3 years? ❑ Nanny ❑ Babysitting ❑ Daycare centre for children ❑ Tutoring children ❑ Caring for a younger family member (also if it was not within the last 3 years) ❑ Au pair ❑ Summer activity camps ❑ Youth or church group/club ❑ Practical training in childcare and related subjects ❑ Other Please detail the areas that describe all the ways in which you have gained childcare experience. Include experience with members of your own family (paid or voluntary) regardless of the ages of the children, or if it is over 3 years ago.
	Areas of experience (see above e.g. baby sitting, tutoring)	Date (Month/year) From - To	Name & ages of children, when you started caring for them Name - age started	Outline experience( E.g. playing, preparing foods, bathing, other acitivities)	How often did you care for these children? (E.g. “2 hours three times a week”, “ 8 hours 1 day a week)”	Total number Of hours in the area of experience	Please indicate (✓) if reference is provided, giving the name of the reference
	EXAMPLE: Babysitting	March 06 - Dec 06	Ava – 2 years Paulo – 5 years	Playing games, Reading Preparing snacks	3 hours 1 day a week	216 hours	✓ Xxxxxxxx Xxxxxxx

Please provide details of any experience you have caring for children with mental, physical or learning disabilities

Statement: ❑ I confirm that the above information is a true and correct record of my experience and that I have at least 100 hours of practical childcare experience gained outside my own family within the last 3 years.

If you need to describe additional child care experience, you can use the space below:

Areas of experience (see above e.g. baby sitting, tutoring)	Date (Month/year) From - To	Name & ages of children, when you started caring for them Name - age started	Outline experience( E.g. playing, preparing foods, bathing, other acitivities)	How often did you care for these children? (E.g. “2 hours three times a week”, “ 8 hours 1 day a week)”	Total number Of hours in the area of experience	Please indicate (✓) if reference is provided, giving the name of the reference
EXAMPLE: Babysitting	March 06 - Dec 06	Ava – 2 years Paulo – 5 years	Playing games, Reading Preparing snacks	3 hours 1 day a week	216 hours	✓ Xxxxxxxx Xxxxxxx

Name of applicant:

To be completed by childcare referee – please use black ink.

Name of Referee (please print): Profession: Company: Address: Telephone (day): Evening: Mobile: Best time to call: Please note that an Au Pair Australia interviewer will contact you regarding this reference.

Are there any dates in the near future when you will not be contactable? (e.g. vacation) Are you related to the applicant? ❑ Yes ❑ No (a relative may not complete this form)

How long have you known the applicant? How do you know the applicant? How many children was the applicant responsible for? Please list all ages of the children at the time the applicant cared for them:

Age when started: Age of children now: How long has the applicant cared for these children? From To How often does/did the applicant care for these children? (e.g. daily, once a week, several times a week)

Please give a full account of the applicant’s duties:

Describe any special skills and abilities the applicant showed:

To the best of your knowledge, has the applicant ever been involved in a criminal offence? ❑ Yes ❑ No

If yes, give details: Has the applicant any health or family problems? ❑ Yes ❑ No If yes, give details:

Please give your opinion of the applicant’s ability to handle new situations and possible stress, culture shock etc:

Please rate the applicant’s qualities in the following area: 1 = poor, 2 = below average, 3 = satisfactory, 4 = good, 5 = excellent

❑ Love of children ❑ Understanding the children’s needs ❑ Responsibility/maturity ❑ Patience

❑ Independence ❑ Reliability ❑ Ability to take initiative ❑ Warmth/compassions

❑ Ability to work with adults ❑ Ability to carry out instructions

Would you recommend the applicant for Au Pair in Australia? ❑ Yes ❑ No Please give details:

Please provide any additional information about the applicant which would be helpful to a prospective family:

Signature Date

PLEASE RETURN TO THE APPLICANT UPON COMPLETION

AIFS Au Pair Character Reference

Name of applicant:

To be completed by character referee.

Name of Referee (please print) Profession Address Telephone (day) Evening Mobile Best time to call

Please note that an Au Pair Australia interviewer will contact you regarding this reference.

Are there any dates in the near future when you will not be contactable? (e.g. .vacation) Are you related to the applicant? ❑ Yes ❑ No (a relative may not complete this form)

How long have you known the applicant? How do you know the applicant? How would you describe the applicant’s personality and character?

To the best of your knowledge, has the applicant ever been involved in a criminal offence? ❑Yes ❑ No

If yes, give details: Has the applicant any health or family problems? ❑ Yes ❑ No If yes, give details:

Please give your opinion of the applicant’s ability to handle new situations and possible stress, culture shock etc:

Please rate the applicant’s qualities in the following area: 1 = poor, 2 = below average, 3 = satisfactory, 4 = good, 5 = excellent

❑ Responsibility/maturity ❑ Independence ❑ Patience ❑ Honesty

❑ Ability to work with adults ❑ Ability to carry out instructions ❑ Warmth/ compassion

❑ Flexibility ❑ Communication skills ❑ Punctuality ❑ Reliability

Would you recommend the applicant for placement as au pair in Australia? Please give reasons in as much detail as possible.

Please provide any additional information about the applicant which would be helpful to a prospective family.

Signature Date

PLEASE RETURN TO THE APPLICANT ONCE COMPLETED.

(to be completed by you and reviewed by your doctor)

Applicant’s name:

Tick the appropriate boxes if you presently suffer from, or ever had:

❑ Tuberculosis

❑ Typhus

❑ Anaemia

❑ Arthritis

❑ Ulcers

❑ Venereal disease

❑ Herpes (cold sores)

❑ kidney disease

❑ Malaria

❑ Chicken Pox

❑ Mumps

❑ Measles

❑ German measles

❑ Whooping Cough

❑ Diphteria

❑ Tetanus

❑ Scarlet fever

❑ Polio

❑ Eye problems

❑ Heart disease

❑ menstrual problems

❑ Rheumatic fever

❑ Epilepsy/Convulsions

❑ Pregnancy/Miscarriage or Termination

❑ Hernia

❑ Varicose veins

❑ Asthma

❑ Ear infection

❑ Gall bladder problems

❑ Bulimia

❑ Anorexia

❑ Depression

❑ sleep walking

❑ Diabetes

❑ Anxiety

❑ glandular fever

❑ Migraines/headaches

❑ Dizziness / Fainting Hepatitis

❑ A ❑ B ❑ C

❑ other:

If you have ticked any of the above, give details including dates:

For the program you need immunisation against Measles, Mumps, German Measles (Rubella), Chicken Pox and Whooping Cough. You also need to have been vaccinated against Tetanus and Diphtheria within the last 10 years. If you are going to be working with young children, it is recommended to have had the whooping cough vaccination within the last five years. Please indicate which disease you still need to get vaccinated for:

Other than the completion of this form, have you visited the doctor or been hospitalised within the last 12 months, if yes, why?

Have you ever received counselling and /or medication for a nervous problem, eating disorder, depression, anxiety or emotional problem?

❑ Yes ❑ No If yes, give details and dates:_ Have you ever been a victim of sexual, emotional or physical abuse? ❑ Yes ❑ No If yes, give details and dates:

Do you have any food allergies? ❑ Yes ❑ No If yes, please specify:

Do you have any allergies to animals? ❑ Yes ❑ No If yes, please specify:

Do you have any allergies to medications? ❑ Yes ❑ No If yes, please specify:

Do you have any other allergies ❑ Yes ❑ No If yes, please specify:

Do you have any habits which may affect your health (e.g. alcohol, cigarettes, drugs)? ❑ Yes ❑ No

Is your physical ability restricted in any way? ❑ Yes ❑ No Do you carry any infectious diseases such as Hepatitis or the HIV virus in your blood? ❑ Yes ❑ No

Are you currently taking any medication? ❑ Yes ❑ No If yes, please specify: Do you have any chronic or recurring illnesses? ❑ Yes ❑ No If yes, please specify:

I understand and agree that host families may have access to this medical information. I give permission to my Doctor completing Part B to review all my responses in Part A and to provide or discuss additional information, if requested to do so by AIFS.

Should an emergency arise, I authorise any medical provider to release information regarding my condition to AIFS, their partners or insurance providers / emergency assistance services and understand that they can contact my next kin, without my prior consent.

The above information is correct to the best of my knowledge and I hereby give permission for emergency medical care to take place should it be necessary. I also understand that withholding or falsifying any information contained on Part A & B may result in my withdrawal from the AIFS Au Pair program.

Signature Date

(to be completed by doctor)

Applicant’s name:

How long have you known the applicant? Are you related to the applicant? ❑ Yes ❑ No (relatives may not complete this form)

Please review the information provided in Part A and give your opinion of the applicant’s general state of health:

❑ Excellent ❑ Good ❑ Fair ❑ Poor

Immunizations

Please ensure that the applicant is currently immune to the following (by vaccination or after the illness):

Measles: Date of vaccination: / Date of illness: Mumps: Date of vaccination: / Date of illness: German Measles (Rubella) Date of vaccination: / Date of illness: Chicken Pox: Date of vaccination: / Date of illness:

Diphtheria Date of vaccination:

Tetanus Date of vaccination:

Whooping Cough Date of vaccination: / Date of illness: Immunity to Whooping Cough after the illness needs to be proven by blood test.

Date of positive blood test:

Please also indicate whether the applicant has been immunized against the following:

Polio ❑ Yes ❑ No Date:

Tuberculosis(TB) ❑ Yes ❑ No Date: Typhoid ❑ Yes ❑ No Date:

General Health

Tick the appropriate box if there are any abnormalities to the following systems:

❑ Ear, nose and throat ❑ Eyes ❑ Neuropsychiatric ❑ Metabolic

❑ Genitourinary ❑ Skin ❑ Cardiovascular ❑ Musculoskeletal

❑ Brain, nervous system ❑ Gastrointestinal ❑ Respiratory system/lungs ❑ Other

If you have ticked any of the above, please give details and dates:

Emotional Health

Is the applicant currently or has ever been treated /counseled or received medication for a nervous condition, eating disorder, depression, anxiety or emotional problem? ❑ Yes ❑ No

If yes, give details and dates and comment on the applicant’s present emotional well being:

Does the applicant have any history of physical, emotional or sexually related problems (i.e. abuse)? ❑ Yes ❑ No

If yes, please comment:

Contagious Diseases

Is the applicant, to the best of your knowledge, a likely carrier of any infectious disease such as Hepatitis B or C, or the HIV virus? (The applicant does not need to be tested) ❑ Yes ❑ No

Has the applicant been hospitalized for more than three days? ❑ Yes ❑ No

If you have ticked yes above, please give details and dates, if applicable:

Please use this space to give any additional relevant information:

Name of Doctor: Address: Telephone No.: Signature and practice stamp: Date:

Vous suivrez une orientation de 2 jours à Sydney. Vous rencontrerez vos coordinateurs dans les locaux d’AIFS situés en plein cœur de Sydney. Vous aborderez différents sujets : votre séjour au pair, des conseils de sécurité avec les enfants, votre quotidien, conduire en Australie, que faire en cas de problème, les procédures de replacement, et des informations générales sur l’Australie. Et depuis cette année AIFS vous fait suivre une demi-journée de formation au secourisme !

Cette orientation est gratuite mais vous avez la possibilité de prendre un pack qui inclut :

🞎 OPTION 1 : la prise en charge à l’aéroport, le transfert jusqu’à l’auberge, 3 nuits en auberge de jeunesse avec petit-déjeuner et une carte Sim avec A$10 de crédit, au prix de A$315.

🞎 OPTION 2 : réserver vous-même une auberge ou un autre logement pour ces 3 jours.

Merci de nous indiquer votre choix en cochant l’option qui vous intéresse.

Le règlement de l’option 1 s’effectuera à confirmation de votre placement en même temps que vos frais d’assurance.

Nom :

Prénom : Signature :

Date :

00, xxx xx Xxxx 00000 Xxxxx – Xxxxx Xxxxx. Tél. 00 00 00 00 00 – Fax 00 00 00 00 00 E mail : xxxxxxxxxxxxxxxx@xxxxxxx.xx Site web : xxx.xxxxxxxxxxxxxxxx.xxx Association régie par la loi 1901

AIFS Au Pair Insurance Agreement

In order to participate as an Au Pair on the 6 month AIFS Au Pair programme you will be required to purchase 7 months insurance from AIFS’ insurer, CareMed at a cost of AU$595.00. This requirement ensures all Au Pairs have the necessary level of insurance cover during their Au Pair placement and allows AIFS staff to provide advice about the policy when requested by the Au Pair.

Au Pairs seeking to extend their stay in Australia may extend their cover by purchasing additional insurance at AU$85.00 per month. Au Pairs wishing to extend their Au Pair placement are required to extend their insurance with CareMed.

Details about the policy and the level of cover will be provided in your pre-departure information.

I agree to purchase AIFS Au Pair’s insurance upon confirmation of my Au Pair placement. I understand that if I do not purchase this insurance I will be unable to participate on the AIFS Au Pair program.

Signature: Date:

Witness’ name:

Witness’ signature: Date:

This document must be emailed to xxxxxx@xxxx.xxx.xx no less than 7 days prior to your scheduled arrival date in Australia. Failure to sign and return this Agreement within 14 days of your scheduled start date may result in the suspension of your placement and may lead to cancellation from the programme.

RECAPITULATIF

Je soussigné(e)………………………………………………certifie avoir pris connaissance de tous les documents fournis par l’association EUROPAIR SERVICES et remplir tous les critères exigés.

Je certifie que j’ai répondu à toutes les questions en toute honnêteté et que toutes les informations fournies dans mon dossier sont vraies.

Je vous adresse mon dossier complet et m’engage à informer l’association EUROPAIR SERVICES de tout changement relatif aux informations fournies dans mon dossier.

IMPORTANT :

Europair Services ne peut être tenu responsable des accidents, pertes, dommages, plaintes où dépenses particulières en relation le séjour des participants.

Le chèque de cotisation doit être joint au dossier, mais ne sera encaissé que lors de la confirmation de votre placement. En cas de non placement, les frais de cotisation seront intégralement remboursés. En cas d’annulation de votre part, les frais d’adhésion et de cotisation resteront acquis à l’agence et ne seront pas remboursés.

Date : Signature :

EUROPAIR SERVICES 00, xxx xx Xxxx 00000 Xxxxx – Xxxxx Xxxxx. Tél. 00 00 00 00 00 – Fax. 00 00 00 00 00

E mail : xxxxxxxxxxxxxxxx@xxxxxxx.xx Site web : xxxx://xxx.xxxxxxxxxxxxxxxx.xxx

2017 AIFS Au Pair Program Rules

I am aware that being an Au Pair requires a high degree of both responsibility and flexibility and that I must take my duties seriously. I agree to abide by the terms and conditions set forth in these Program Rules as detailed below.

1. I shall carry out my child care duties responsibly and in a caring and considerate manner. I agree my childcare responsibilities will take precedence over my own personal and/or social life. I shall make a concerted effort to experience the culture of my host country, to learn the language, and to display tolerance towards others.

2. I understand that the safety of my Host Family’s children will be my priority for the duration of my program. I shall seek the advice of the Host Family before administering any form of discipline on the children. Any physical harm to the children will result in my instant termination of the program and I accept responsibility for any further consequences.

3. I undertake to fulfill all the responsibilities agreed upon with the Host Family which may include, but is not limited to, house rules and a weekly schedule. I understand that I shall be asked to undertake light/ childcare related household duties and to make a fair contribution to the cleanliness of the common areas of my Host Family’s home. I agree to keep my own room clean and tidy as well as participate in the day-to-day life of my Host Family.

4. I shall make every effort to resolve any differences with my Host Family. If I am being treated unfairly regarding the Host Family’s attitudes, workload, housework, I will bring the matter to the attention of the Host Family and contact my assigned Coordinator. In addition, should I be subject to any physical, sexual or emotional abuse from any member of the Host Family, I agree to immediately contact my Local Coordinator.

5. I agree that I will provide the agreed number of hours per week of services to my Host Family. I understand I will have at least 1.5 days off per week, which do not have to be on a weekend or consecutive days.

6. I understand that a two-week Notice Period must be respected and observed once the placement is cancelled. During this period, I shall perform my normal duties and I shall continue to receive room, board, and pocket money. In case my host family releases me from my childcare duties, I won’t receive pocket money anymore. I understand that a replacement into a new family may involve moving to a different area/city, the transport

AIFS Au Pair 2015 1

costs will have to paid by me. As replacements are subject to availability, AIFS can’t guarantee to place me with another Host Family by the end of the notice period, I will have to leave the family and pay for my own accommodation & food.

7. I agree my weekly pocket money and bonus will be based upon my experience and the program I choose:

Program	Hours	Pocket Money	Bonus (to be paid upon completion by the host family)
Au Pair Start	25-35 hours	$200	$500
Au Pair Start	36-45 hours	$250	$500
Au Pair Plus	25-35 hours	$200	$500
Au Pair Plus	36-45 hours	$250	$500
Au Pair Platinum	25-35 hours	$240	$500
Au Pair Platinum	36-45 hours	$290	$500

8. I accept total responsibility of my own expenses, including but not limited to, long distance phone calls, dry cleaning, medical expenses not covered by my travel insurance and any other personal expenses incurred by myself or by the Host Family on my behalf. Neither AIFS nor the Host Family will accept responsibility for any personal charges or extra expenses that I have incurred.

9. I understand that my program will be terminated without compensation if:

● I fail to abide by the terms and conditions of the Program or the Program Rules

● I falsify any information in my application

● I administer corporal punishment to a child

● I act in a neglient manner that endangers my host family, or their property

● I am responsible for repeated problems with several host families

● I disobey Australian laws.

Au Pair Applicant Print Name

Au Pair Applicant Signature Date

AIFS Au Pair 2015 2

Education
Please tick the levels of education that you have achieved and complete the table below giving full details of all your educational achievements after elementary school.

Level of education e.g. High school, college technical college, university

Dates(month, year)

From To

Qualification gained e.g. High school certificate A Levels, Diploma

Subjects studied

Experience and Goals
Give a brief summary of all the jobs – except childcare experience - that you have held with the dates and an explanation of your duties:
Job title Dates Duties

When you return to your home country at the end of the program, what do you intend to do? (e.g. study, work)                                                   What do you expect to gain from the program for your future?

What are your long term career goals?

Have you visited other countries before? ❑Yes ❑ No If yes, which countries?            Have you ever travelled outside your home country for 2 months or more? List locations, dates and reasons