Cultural Care ee ___}
Au Pair
Childcare Reference
Tote iene = ‘napping Culaoal Car (gered bans name of btratonal Care Lid)
‘beam ax prince Unie Stas fron ear Please ans he fabowing as bane and camel a posible. The aera eae to anti placing che
apphcan wish a fails Uy do ns el comfrable writing in Engl; pose flow the firence myo ative language. You il be contacted bythe leat effete
a ein
1, Hoy did you getro know the applicant employes, aeighbor tacheret)?
2. How do yo ltow thatthe pplican ca tke eae of chien?
(The applicanehastaken caw oF mychilden C1] havesupervised the applicae (eg. Camp dirctor childcare center manages}
(We have worked gether with citien CJOthe
‘When did te aplicanc ake ca f the childsen Suse (dates) month__year__ Seppe (tes) momth_yean_ Ongoing
Has the applicant ake cae of thee children when they were under she age of ro? Yer CIN
5._ Please wite down the sex and ae ofthe chide the applicant ard for (fina group sing, please write the numberof chien and the age range)
Nameaf the children (Fagiaup. plone wit # of chilven) | Sox(WIF| [Age of thechidien when sured | Age of the chldien when stopped
Please specify he eel of mzponaiblie the applic: had when cele cared forthe chikben: C1 Hep Fall epoasible
What ime of day dt he applican: cae for che chilven: Dey (Evening Overnight! Weekends
18. What ype of aceite did the applicant do whale raking cre ofthe chileren?
9, Plese describe why you think the applicant would be 2 goodau pai:
10. Mlseadd any informatio you would like 0 give about the palin
11, Compete the following
Nave caption
Phone - —=s ____ Woskimobile phone
Adres - Pose code/ Cit =
Ell est into seach you:
Sigutace Date
A prospective os fuily may contact you fora reference. Do you speak English? [Yes [IN
FOROFFICEUSE ONLY
Commens: =
Therenee confirm etal biar hoses cad. ntl infra
My ignaure coisa Tha rpoken withthe rforme ited shone, weil th ddr experience inclading the cider hours as ine abe a
cone ht the alton, Fy acura.
Nain (pi wid ia Date: