Au Pair

Documentos AuPairCare
Instrues de Preenchimento e Check list
Parabns por sua deciso de participar do programa Au Pair nos EUA pela CI! Abaixo apresentamos algumas informaes importantes de como preencher o application.
Como preencher seu application AuPairCare on line O preenchimento do seu application o passo mais importante de seu processo: atravs dele, as famlias conhecem seus interesses, aptides e podem escolher voc. Coloque-se no lugar da famlia: O que voc gostaria de ver no application? Passo a passo 1- Preencha o application on line (no use acentos pois desconfiguram o application) 2- Imprima o application 3- Encaminhe application impresso e demais documentos para a CI (lista de documentos disponvel no check list ao final deste documento) application (boto IMPORTANTE: Voc no deve clicar em Submit application verde no canto inferior direito) antes de receber a confirmao da CI que acontecer aps o recebimento de todos os documentos. documentos. Segue abaixo instrues de itens que devem ser observados. Voc dever preencher todos os itens. Veja abaixo algumas dicas. dicas. Seja sincera! Caso seja constatado em qualquer etapa do programa que a informao prestada no verdadeira, a famlia poder pedir seu desligamento do programa. Application on line 1- Personal information Name: Digite seu nome exatamente como est em seu passaporte. Exemplo: First Name: Juliana nmero do DDD tambm. Ex.: 11- 2222-2222 Informe os melhores horrios para que a famlia entre em contato com voc em cada nmero. Last Name: Paes Leme Phone number: O cdigo do Brasil 55. Lembre-se de informar o
Ao final, selecione a data mais prxima que voc poder chegar aos EUA. Note que a data selecionada no significa que voc embarcar na mesma. Aps preencher todos os dados, clique em Save & Continue 2- Childcare Childcare skills Selecione todas as opes que se aplicam a voc em relao idade das crianas que tem experincia, idade das crianas que quer cuidar. Note que quanto mais flexvel, melhores so suas chances de colocao. Selecione tambm as opes em relao ao tipo de cuidado com crianas que tem experincia. Responda a pergunta sobre suas habilidades em atividade em casa. Caso tenha experincia com crianas especiais, informe e detalhe. Aps preencher todos os dados, clique em Save & Continue. 3- Childcare experience Essa seleo o seu CV sobre sua experincia com crianas. Voc poder adicionar tantas experincias quanto tiver. Note que voc poder incluir experincias com familiares caso sejam com menores de 2 anos, na opo Babysitting. Somente sero consideradas como parte integrante das 200 horas mnimas requeridas caso seja com crianas nesta faixa etria. Para cada experincia, escolha o tipo (Babysitting, Nanny, Au pair, Siblings/family, daycare, teaching ou camp) Faa uma lista de suas experincias em um papel e quando pronta, preencha o formulrio on line. Note que as horas sero calculadas de acordo com a informao prestada neste item. Para completar duzentas horas mnimas de experincia com maiores de 2 anos, no so consideradas as horas com famlia. Entretanto, no deixe de listar. Aps preencher todos os dados, clique em Save & Continue. 4- Education & Career Neste item, so solicitadas informaes sobre sua vida acadmica. Informe todos os detalhes.
Note que as pessoas que incluir como referncia, poder receber uma ligao para confirmar os dados. Informe caso tenha alguma experincia profissional alm de cuidar de crianas. Aps preencher todos os dados, clique em Save & Continue 5- Family information Inclua os dados de sua famlia e descreva a mesma assim como sua relao com eles. Aps preencher todos os dados, clique em Save & Continue. 6- Driving Experience muito importante para a famlia que voc saiba dirigir, por isso, preencha todos os itens desta etapa e demonstre flexibilidade e boa vontade. um requisito ter carteira de motorista. Voc pode incluir comentrios ou no. Lembre-se de que a famlia gostar de ter o mximo de informaes sobre voc. Aps preencher todos os dados, clique em Save & Continue. 7- Personal Characteristcs Seja sincera em todas as respostas. Na pergunta: Do you smoke? Responda, lembrando que um dos requisitos do programa no fumar. Para quem fumante, a colocao mais difcil. Na pergunta sobre os animais de estimao, note que a maioria das famlias tem animais de estimao. Caso sua resposta que tem alergias, sua colocao pode ser mais demorada. Descreva seus hobbies, pois as famlias consideram esta resposta para verificar quais os interesses em comum. Aps preencher todos os dados, clique em Save & Continue. 8- Personality Selecione na lista, as opes Not at all, Somewhat , Very Much em cada frase para descrever sua personalidade. Escolha no item seguinte quatro palavras que um amigo usaria para descrever voc. Aps preencher todos os dados, clique em Save & Continue.
9- Short answer questions Esta etapa deve ser preenchida com muito cuidado, j que so respostas que vo dar detalhes sobre como voc . Mais uma vez, lembre-se ao responder de que as famlias escolhero voc por suas respostas. Revise a escrita e evite erros de digitao. Aps preencher todos os dados, clique em Save & Continue. 1010Health
Preencha todos os itens e detalhe no caso de ter respondido algum Sim. Novamente lembramos da importncia de ser verdadeira em seu application e para participar do programa necessrio que esteja em perfeitas condies de sade. Aps preencher todos os dados, clique em Save & Continue. 1111Letter to Host family
A carta um dos itens mais importantes do seu application. Note que existe limite de caracteres. Diga seus motivos de querer cuidar de crianas nos EUA. Fale de sua experincia com crianas e como gosta de crianas, d detalhes. Fale de sua famlia, interesses, personalidade. Explique porque a famlia deveria te aceitar como sua au pair. Evite falar de seu namorado. No mencione o nmero de crianas que quer cuidar. No mencione preferncia por uma regio especfica. LembreLembre-se de revisar a escrita! Character Reference Deve ser totalmente preenchido pela pessoa que possa dar uma opinio sobre voc. No pode ser Passo a passo: - Aps sua referncia preencher o formulrio em portugus, passe as respostas para o formulrio em ingls; - As referncias assinam ambas as verses; - Envie as duas verses (ingls e portugus) para a CI. parente. Sugerimos chefe, professor. Se no for possvel, pode ser amigo ou vizinho.
Childcare reference Deve ser totalmente preenchido pela pessoa que possa dar a referncia sobre sua experincia com crianas. As duas referncias profissionais devem ser de lugares diferentes. Passo a passo: - Aps sua referncia preencher o formulrio em portugus, passe as respostas para o formulrio em ingls; - As referncias assinam ambas as verses; - Envie as duas verses (ingls e portugus) para a CI. Note que as informaes no application on line e referncias devem coincidir. Physician Verified Medical History. History. Deve ser preenchido completamente pelo medico, assinado e carimbado. Ao terminar de preencher, clique no canto superior direito em print my application e encaminhe o mesmo com os demais documentos do Check list para a CI. Depois, clique em logout para sair. Aguarde o contato da CI para que voc entre novamente em seu application on line e clique em Submit my application. Outras dicas: Fotos on line Use fotos suas com crianas e famlia. Fotos no formato jpeg de qualidade, que no sejam com decotes, mini-saias, bebidas, barriga de fora etc. Para salvar, informe a legenda no quadro caption Somente sero salvas fotos no formato jpeg e que estejam com legenda. Quantidade mnima 10 fotos.
Vdeo Online 10 dicas para criar um bom vdeo: 1. Grave seu filme em um lugar silencioso e com boa luminosidade; 2. Mantenha contato visual com a cmera, no desvie o olhar enquanto estiver falando; 3. Fale devagar, com clareza e sorria; 4. Este um vdeo curriculum, no fale sobre coisas que voc no falaria em uma entrevista comum e vista-se adequadamente; 5. Inicie seu filme saudando a famlia e depois fale seu nome, idade e pas; 6. Aps sua apresentao famlia fale sobre estes tpicos: a. Por que voc quer ser uma Au Pair; b. Por que voc acredita que a famlia deva escolher voc; c. Fale sobre sua experincia com crianas e o que voc mais gosta de fazer quando est cuidando delas; d. Fale sobre seus interesses pessoais, habilidades, seu nvel de educao e seus objetivos; e. Fale sobre sua cidade e pas. 7. Se possvel acrescente ao seu vdeo cenas onde voc est cuidando das crianas: dando de comer, nadando, ajudandoas com a lio de casa, brincando, etc; 8. Seja criativa! Se voc faz esportes, pinta, toca algum instrumento, ou tem qualquer outra habilidade, insira no vdeo; 9. Voc pode agradecer famlia por ter assistido seu filme e dizer que espera que ela entre em contato; 10. Reveja seu vdeo e o edite se necessrio, antes de fazer o upload dele no Au Pair Room. Requerimentos do vdeo: 1. Deve ter no mnimo 1 minuto e no mximo 3; 2. O vdeo deve estar em um dos seguintes formatos: MPEG, MOV, AVI, WMV ou FLV.
ATENO: ENVIAR 02 (DUAS) VIAS DE CADA DOCUMENTO
Check List
Confira todos os itens e a seqncia dos documentos abaixo antes de enviar por sedex para a CI ou entregar pessoalmente em um de nossos escritrios. Documentos incompletos no podero
ser enviados organizao internacional.
Slep Test (mnimo de 55 pontos)
Au Pair Application on line
Physician verified Medical History
2 Childcare References (portugus e ingls)
Character Reference (portugus e ingls)
Au Pair Agreement 2010
Structured Interview (entrevista realizada pela CI)
Psychometric Test
Au Pair Care Interview (entrevista feita pela loja CI)
Atestado de Antecedentes Criminais (1 via em portugus e 1 via em ingls).
Comprovante de escolaridade (1 via em portugus e 1 via em ingls no precisa ser juramentada pode ser ensino mdio ou universitrio)
Cpia da carteira de motorista
Cpia do passaporte (as duas primeiras pginas)
Condies Gerais CI assinada.
PERSONAL/CHARACTER REFERENCE The applicant presenting you with this form is a candidate for the AuPairCare program. If accepted, he/she will spend a year with an American family taking care of and being responsible for the children in this family. NOTE: This reference must be completed by a NON-RELATIVE and will be verified by an AuPairCare representative. You may be contacted to verify this reference. 1. Name of applicant: __________________________________________________________________________ 2. How long have you known this applicant? ______________________________________________________ 3. How do you know this applicant? Employer Friend Active Adaptable Creative Efficient Neighbor Colleague Family-oriented Flexible Humorous Independent Open-minded Outgoing Polite Positive Teacher Other _____________________ Sociable Sporty Warm-hearted Other ______________
4. How would you describe this persons character?
5. Please describe why you believe the applicant is suitable for the AuPairCare program. List any relevant skills and abilities the applicant has demonstrated: _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ 6. Do you recommend this applicant for the AuPairCare program? Yes No Please explain: _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ 7. Additional comments on the applicants character: _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ 8. Reference Information: Name: _______________________________________________________________________________________ Address: _____________________________________________________________________________________ Signature: __________________________________________________________ Date: _____/_____/________ 9. May a prospective host family call you? Yes No, I am uncomfortable speaking English. Daytime Phone: (011) _______________________
Country Code / Area Code / Local Number
Email Address: ____________________________ Evening Phone: (011) _______________________

For Office Use Only: Verified by: _________________________________________________________ Date: _____/_____/________
AuPairCare 600 California Street Suite 10, San Francisco, CA 94108 Tel: 415-434-8788 Fax: 415-434-5415 www.aupaircare.com
REFERNCIA PESSOAL
Se a candidata ao programa AuPairCare que o apresenta neste formulrio for aceita ela ir passar um ano com uma famlia americana, cuidando e sendo responsvel pelas crianas dessa famlia. NOTE: Essa referncia no deve ser preenchida por uma familiar e ser verificada por um representante da AuPairCare. Voc poder ser contactado para comprovao dessa referncia. 1. Nome da candidata: __________________________________________________________________________ 2. H quanto tempo voc conhece a candidata? ______________________________________________________ 3. Como voc conheceu a candidata? Empregador Amigo Ativa Adaptvel Creativa Eficiente Vizinho Colega Bem orientada Flexiva Bem Humorada Independente Professor Outro _____________________ Mente aberta Extrovertida Sensvel Positiva Socivel Esportiva Outro______________
4. Como voc descreve a personalidade da candidata?
5.Por favor descreva o por que voc acredita que a candidata possui perfil para a AuPairCare. Liste qualquer habilidade relevante que a candidata tenha demonstrado: _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ 6. Voc recomenda a candidata para o programa AuPairCare? Sim No Por favor, explique: _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ 7. Comentrios adicionais sobre a personalidade da candidata: _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ 8. Informaes da referncia: Nome: _______________________________________________________________________________________ Endereo: _____________________________________________________________________________________ Assinatura: __________________________________________________________ Data: _____/_____/________ 9.Uma futura hostfamily poder ligar para voc? Sim No, no me sinto bem falando em ingls.
Cdigo pas / Cdigo rea / Nmero
Email: ____________________________
Telefone comercial: (011) _____________________Telefone residencial: (011) _______________________ Somente para uso da loja: Verificado por: _________________________________________________________ Data: _____/_____/______
CHILDCARE REFERENCE
The applicant presenting you with this form is a candidate for the AuPairCare program. If accepted, he/she will spend a year with an American family taking care of and being responsible for the children in this family. NOTE: This reference must be completed by a NON-RELATIVE and will be verified by an AuPairCare representative. You may be contacted to verify this reference. 1. Name of applicant __________________________________________________________________________ 2. How long have you known this applicant? ______________________________________________________ 3. How do you know this applicant? Employer Friend Neighbor Colleague Other _____________________
4. How do you know that the applicant can take care of children? The applicant has taken care of my children We have worked together with children I have supervised the applicant with children Other: __________________________________
5. When did the applicant care for the children? Start Date: _____/_____/_____ Stop Date: _____/_____/_____ 6. How frequently did the applicant take care of the children? Hours per week: _____ Weeks per month: _____ 7. Please list the ages of the children for whom the applicant cared: 0-6 months 6-12 months 1-2 years Bottle feeding Spoon feeding Burping Changing diapers (nappies) Bathing 2-5 years 5-10 years 10 years and older Meals preparation Playing with children Helping with schoolwork Putting children to bed Other _________________________________________________
8. Please state the applicants duties and activities during this period:
9. Please describe the skills and abilities this applicant showed while caring for the children: _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ 10. Do you recommend this applicant for the AuPairCare program? Yes No Please explain: _____________________________________________________________________________________________ _____________________________________________________________________________________________ 11. Reference Information: Name: _______________________________________________________________________________________ Address: _____________________________________________________________________________________ Signature: __________________________________________________________ Date: _____/_____/________ 12. May a prospective host family call you? Yes No, I am uncomfortable speaking English. Daytime Phone: (011) _______________________


REFERNCIA PROFISSIONAL
Se a candidata ao programa AuPairCare que o apresenta neste formulrio for aceita ela ir passar um ano com uma famlia americana, cuidando e sendo responsvel pelas crianas dessa famlia. NOTE: Essa referncia no deve ser preenchida por um familiar e ser verificada por um representante da AuPairCare. Voc poder ser contactado para comprovao dessa referncia. 1. Nome da candidata __________________________________________________________________________ 2. H quanto tempo voc conhece a candidata? ______________________________________________________ 3. Como voc conheceu a candidata? Empregador Amigo Vizinho Colega Parente Outro_____________________
4. Como voc pode comprovar que a candidata tem capacidade para cuidar de crianas? Ela cuidou dos meus filhos Eu supervisionei a candidata com crianas Outros: __________________________________ Ns trabalhamos juntas com crianas 5. Perodo em que a candidata cuidou das crianas? Data de incio: _____/_____/_____ Data final: _____/_____/_____ 6. Com que frequncia ela cuidava das crianas? Horas por semana: _____ Semanas por ms: _____ 7. Por favor liste a idade das crianas que ela cuidou: 0-6 meses 6-12 meses 1-2 anos Dar mamadeira Dar de pap Fazer arrotar Trocar fraldas Dar banho 2-5 anos 5-10 anos 10 anos ou mais Preparar refeies Brincar com as crianas Ajudar com o dever de casa Por para dormir Outro _________________________________________________
8. Por favor liste as atividades e deveres durante este perodo:
9. Por favor descreva as habilidades que a candidata mostrou enquanto cuidava das crianas: _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ 10. Voc recomenda essa candidata ao Programa AuPairCare? Sim No Por favor, explique: _____________________________________________________________________________________________ _____________________________________________________________________________________________ 11. Informaes da referncia: Nome: _______________________________________________________________________________________ Endereo: _____________________________________________________________________________________ Assinatura: __________________________________________________________ Data: _____/_____/________ 12. Uma futura hostfamily poder telefonar para voc? Sim No, no me sinto bem falando ingls.
Email: ____________________________
Telefone comercial: (011) ____________________Telefone residencial: (011) _______________________ Somente para uso da loja: Verificado por: _________________________________________________________ Data: _____/_____/______
CHILDCARE REFERENCE The applicant presenting you with this form is a candidate for the AuPairCare program. If accepted, he/she will spend a year with an American family taking care of and being responsible for the children in this family. NOTE: This reference must be completed by a NON-RELATIVE and will be verified by an AuPairCare representative. You may be contacted to verify this reference. 1. Name of applicant __________________________________________________________________________ 2. How long have you known this applicant? ______________________________________________________ 3. How do you know this applicant? Employer Friend Neighbor Colleague Other _____________________
4. How do you know that the applicant can take care of children? The applicant has taken care of my children We have worked together with children I have supervised the applicant with children Other: __________________________________
5. When did the applicant care for the children? Start Date: _____/_____/_____ Stop Date: _____/_____/_____ 6. How frequently did the applicant take care of the children? Hours per week: _____ Weeks per month: _____ 7. Please list the ages of the children for whom the applicant cared: 0-6 months 6-12 months 1-2 years Bottle feeding Spoon feeding Burping Changing diapers (nappies) Bathing 2-5 years 5-10 years 10 years and older Meals preparation Playing with children Helping with schoolwork Putting children to bed Other _________________________________________________
8. Please state the applicants duties and activities during this period:
9. Please describe the skills and abilities this applicant showed while caring for the children: _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ 10. Do you recommend this applicant for the AuPairCare program? Yes No Please explain: _____________________________________________________________________________________________ _____________________________________________________________________________________________ 11. Reference Information: Name: _______________________________________________________________________________________ Address: _____________________________________________________________________________________ Signature: __________________________________________________________ Date: _____/_____/________ 12. May a prospective host family call you? Yes No, I am uncomfortable speaking English. Daytime Phone: (011) _______________________


Physician Verified Medical History

Note to Physician: The person presenting you with this form is applying to be an au pair with AuPairCare. If accepted, he/she will spend a year with an American family taking care of the familys children and being responsible for them. It is important that the people we entrust with this responsibility be in good health. Please provide in depth medical history and attach additional documentation if necessary.
Name of Patient: ____________________________________________ Age: ________________________ Height: _____________________
Date of Birth: _______/_______/_______ (month/day/year) Weight: _________________________________________
1. Does this patient have or have they ever suffered from or been diagnosed with any of the following? Indicate by checking "Yes" or "No" for each condition. Any disease or abnormality of:
Yes No Yes No Yes No
General health:
Yes No
Anorexia Allergies Bulimia Chicken pox Diabetes Epilepsy Hernia HIV/AIDS Hepatitis Measles
Meningitis Mumps Rubella Scarlet fever Serious or persistent cough Serious or persistent headaches Tuberculosis Typhoid fever Ulcer Vertigo/Dizziness
Blood or endocrine system Bones, joints or locomotive Brain or nervous system Ears or hearing Eyes or sight Heart Lungs or respiratory system Other abdominal organs Stomach or digestive Tonsils, nose or throat
Genito-urinary issues Mental or nervous disorders Is the patient pregnant? Does the patient have any physical disabilities? Does the patient have any contagious diseases? Does the patient have an alcohol or drug dependency? Does the patient suffer from panic attacks? Does the patient smoke? Other: _____________________________
If "Yes" is checked for any of the above conditions, please explain further and provide the year illness(es) occurred. If the exact year is unknown please provide an approximate year: ____________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________________ 2. Please list all adult inoculations/vaccines/immunizations that have been given to this patient and the approximate month and year received: __________________ ___________________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________________ 3. Has this patient ever been hospitalized? Yes No If yes, please explain:________________________________________________________________
___________________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________________ 4. Has this patient been treated for a medical condition in the past 2 years? Yes No If yes, please explain:_______________________________________
___________________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________________ 5. Does this patient regularly take any medications (excluding birth control)? Yes No If yes, please explain:_______________________________________
___________________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________________ 6. Does this patient have any pre-existing medical conditions? Yes No If yes, please explain:__________________________________________________
___________________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________________ 7. Has this patient ever received psychiatric counseling? Yes No If yes, please explain:_______________________________________________________
___________________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________________
Rev. 11/2008
Page 1 of 2
8. Does the patient have any history or symptoms of an eating disorder such as anorexia, bulimia or other similar conditions?
Yes
No If yes, please explain:
___________________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________________
9. Does the patient present any history or symptom of nervous, emotional, or mental abnormality (i.e. neurosis, nervous breakdown, nervous fatigue, recurrent nightmares, panic attacks, etc.)? Yes No If yes, please explain:_______________________________________________________________________
___________________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________________ 10. Does this patient suffer from any chronic conditions (i.e. asthma, arthritis, diabetes, epilepsy, chronic fatigue, etc.)? Yes No If yes, please explain:______
___________________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________________ 11. Has this patient ever been the victim of physical or sexual abuse? Yes No If yes, please explain:____________________________________________
___________________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________________ 12. Is there any reason why this patient should not care for children? Yes No If yes, please explain:_____________________________________________
___________________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________________ 13. Is there anything more you would like to tell us about this patient? Yes No If yes, please explain:____________________________________________
___________________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________________ 14. In my expert opinion, the general state of the patients health is: Excellent Good Fair Poor
I, the undersigned, have given a thorough physical examination and reviewed the medical history of the patient. I certify that the above information is complete accurate to the best of my knowledge. Physicians Name:______________________________________________________________ Phone Number:______________________________________________________________ Place Physician Stamp Here (or affix business card)
Signature:______________________________________________________________ Date:________/________/________ (month/day/year)
Emergency Operation Release/Waiver (This section must be signed by the au pair applicant)
If my medical condition changes (including pregnancy), between the time of signing this document and my departure to the USA, I understand that I am required to notify AuPairCare and resubmit another Physician Verified Medical History document prior to my arrival. I also understand that failure to adhere to this policy, will likely result in my immediate termination from the program. My signature below indicates that the medical history provided is true and hereby give my full consent to be medically treated or to undergo any emergency operation which is determined by a doctor and may be necessary during my stay abroad. I also accept full responsibility for any medical expenses which are not covered by my insurance policy, and understand that pre-existing medical conditions will not be covered. I also give my full consent to release this information to potential host families. Strong recommendations to the au pair: Travel Insurance does not include the cost of normal dental treatment that is not due to an accident. It is therefore important for any person traveling abroad to receive a thorough dental examination so that no unexpected complications arise during the period of residence abroad.
Au Pair Signature: ___________________________________________________________________ Print Name: ___________________________________________________________________
Date: __________________________________________
Rev. 11/2008
Page 2 of 2
Questionrio
Repeat Au Pair Questionnaire
1. Have you successfully completed an American J-1 au pair program before? 2. Can you provide documentation that shows you have successfully completed your first au pair program? 3. Have you resided outside of the US for at least 2 years after the conclusion of your program? 4. What month and year did you complete your program? 5. Name of the American agency that sponsored your au pair program participation:
Yes
No
Yes
No
Yes
No
______/______ (Month/Year)
I ___________________________, verify that I have successfully completed an American J-1 visa program including the required the educational component. ___________________________ Au Pair Name ___________________________ Date ___________________________ Au Pair Signature
Applicants who are not previous AuPairCare au pairs, must attach documentation proving they have successfully completed a previous American J-1 au pair program.
Au Pair Match Information

Au pairs Name ________________________________________________________________________________ First Last Departure City _________________________________________________________________________________ First possible arrival date _____/ _____/ ______ Day Month Year Last possible arrival date_____/ _____/ ______ Day Month Year
Will the applicant will be out of town during the matching process? Please note the start and stop dates and a contact number while away. Start date _____/ _____/ ______ End date_____/ _____/ ______ Tel. number______________________________ Day Month Year Day Month Year Country Code / City Code / Number Has this applicant ever been denied a visa to the United States?
yes no
If yes, what type of visa? _________________________________________What year? _____________________ Reason(s) for denial____________________________________________________________________________ Does the Applicant have relatives living in the United States?
yes no
If yes, where? ____________________________________________________ How long has the relative been living there? __________________________________________ Is the applicant willing to live with a family of a different religious faith if they do not require the au applicant to participate in their religious practice?
yes no
The US is a home to people of many races and ethnic backgrounds. Is the applicant willing to live with a family of a different race/ethnicity?
yes no yes no
Single father?
Is the applicant willing to live with a single mother?
yes no
Occasionally APC has same-sex host families. Is the applicant willing to living with one? Does the applicant have experience with special needs children?
yes no
Is the applicant willing to take care of special needs children? If yes, please provide the following information about the au pairs special needs experience: Please use an additional sheet of paper if necessary. Childrens ages: Type of special need cared for: Duties/activities:
yes no yes no
Start/end dates of care and frequency of care: Given the instructions provided, please rate the applicants ability to speak and understand conversational English on a scale from 1 to 10 (10 being a native English speaker and 5 being the minimum requirement) 1 2 3 4 5 6 7 8 9 Given an English newspaper or magazine article please rate the applicants reading ability: Excellent Good Fair Poor 10
Interviewers Name (printed) ______________________________________________________________________ Interviewers Signature____________________________________________________ Date _____/ _____/ _____
6/07
Condies gerais
Condies Gerais
AuPairCare - 2011
Este um termo de acordo entre residente CI e em
____________________________________________, ____________________________________, Brasil.
A CI, tem parceria com a organizao AuPairCare (organizao americana sediada em So Francisco), a qual ser responsvel pela Au Pair durante sua colocao e participao do programa. O Au Pair um programa de intercmbio cultural e a participante entende e aceita obedecer as regulamentaes publicadas pelo Departamento de Estado dos Estados Unidos: 22 CFR Part 514, a qual pode sofrer alteraes a qualquer momento. A mesma pode ser visualizada no seguinte endereo: http://exchanges.state.gov/jexchanges/index.html Atesto que li e entendi os termos e concordo com os pontos a seguir: Preo do Programa Entendo que o preo do programa inclui uma taxa administrativa da CI, uma taxa de participao, a qual inclui os itens conforme descritos abaixo: Assistncia Mdica Internacional, passagem area internacional e transporte domstico. O programa no inclui valores inerentes preparao da viagem e despesas pessoais. Assistncia Mdica Internacional Este seguro de assistncia mdica internacional ter cobertura mdica e contra acidentes, totalmente em acordo com as leis e regulamentaes do governo americano. Dentre as principais limitaes, a au pair confirma estar ciente de que doenas pr-existentes no so cobertas pelo seguro. A au pair confirma que as coberturas e limitaes do mesmo foram verificadas, compreendidas e aceitas. Dias adicionais no esto inclusos, portanto, a au pair dever providenciar extenso do seguro, em caso de optar por permanecer no pas no 13 ms ou prorrogao do programa, devidamente aceita pela organizao. A au pair aceita a responsabilidade total de custos mdicos no cobertos pelo seguro.
( ) Iniciais 1
Condies Gerais
AuPairCare - 2011
Taxa de passagem area internacional O programa inclui a passagem area internacional, de ida, com sada de So Paulo ou Rio de Janeiro com destino final em Nova Iorque. Caso a Au Pair conclua os 12 (doze) meses, ter direito a passagem internacional ao Brasil. Os trechos internos no Brasil no esto inclusos. Se por qualquer razo a Au Pair no concluir o programa de 12 (doze) meses, no ter a passagem e, portanto, ter que arcar com o valor integral de uma passagem area internacional para seu retorno ao Brasil. A mesma regra se aplica caso a Au Pair no retorne ao Brasil aps o 13 ms e/ou se no realizar o curso exigido. Transporte domstico Os eventuais vos domsticos no Brasil de ida e volta no esto inclusos no programa. O transporte domstico entre a orientao obrigatria nos EUA e casa da famlia anfitri est incluso no programa. Este transporte poder ser realizado pelo meio de transporte escolhido pela famlia e informado durante a orientao nos EUA. O transporte domstico de retorno est incluso no programa desde que a au pair conclua o programa. PrPr-Requisitos - de 18 a 26 anos - Bom nvel de ingls (mnimo de 55 pontos no Slep Test) - Comprovante de escolaridade mnimo: ensino mdio - Experincia comprovada com crianas (mnimo de 100 horas) em pelo menos dois lugares diferentes, excluindo-se parentes. - Para au pairs que queiram ser colocadas com crianas menores de 2 anos, exigida experincia comprovada com crianas (mnimo de 200 horas) - em pelo menos dois lugares diferentes , uma delas poder ser com parentes. - Carteira de motorista ** - Poder comprovar fortes vnculos com o Brasil - Disponibilidade de 12 meses para a realizao do programa - Perfeita sade fsica e mental - Solteira, sem filhos e no estar grvida
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Condies Gerais
AuPairCare - 2011
*participantes com 18 anos sero aceitas condicionalmente ao fato de se comprometerem a obter carteira de motorista vlida para o perodo todo do programa, sob pena de retornar ao Brasil caso no seja possvel. **Candidatas com pouca experincia em direo podero ser aceitas em carter condicional. Regras 1. Entendo e estou de acordo que a CI e AuPairCare analisem minha qualificao quanto aos pr requisitos, perfil para o programa, veracidade dos dados e decidam a qualquer momento sobre minha aprovao ou no para o programa Au Pair. 2. A CI e a AuPairCare podero solicitar documentos complementares, alterao de fotos entre outros a qualquer momento. 3. Estou de pleno acordo de que as minhas condies de sade mudem (incluindo gravidez), entre o perodo de inscrio e incio do programa, sou responsvel em apresentar novo relatrio mdico Physician Verified Medical History antes do meu embarque. Assim como todas as condies das condies gerais, caso a Au Pair no cumpra com essa regra, ser desligada imediatamente do programa e dever retornar ao Brasil, sendo responsvel pelos custos do retorno. 4. Entendo e concordo que o perodo para minha colocao em uma famlia americana depende de diversos fatores tais como meu perfil, o perfil de famlias, meu application, minha entrevista telefnica etc. Entendo que o perodo mdio de colocao entre trs e quatro meses e este perodo no uma garantia de prazo para confirmao. 5. Durante o processo de seleo, ser permitido que at trs famlias verifiquem e entrem em contato. Minha participao poder ser cancelada, sem direito a devoluo da taxa administrativa. 6. Concordo em executar tarefas relacionadas a cuidar de crianas e tarefas domsticas, em geral, que no excedam (com limitao separadamente): (i) 45 horas semanais; (ii) 5 (cinco) dias e meio por semana; e (iii) o mximo de 10 horas por dia. Receberei direto da famlia anfitri cerca de USD 195,75 (cento e noventa e cinco dlares americanos e setenta e cinco centavos americanos). Entendo que este valor pode ser alterado em funo das leis norte-americanas que regem o programa. Terei, pelo menos, 1 dia e 7. Meio de folga, por semana, e 1 (um) fim de semana inteiro, por ms. Terei tambm duas semanas de frias remuneradas durante o programa.
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Condies Gerais
AuPairCare - 2011
8. Realizarei a orientao pr-embarque obrigatria da CI, bem como a orientao nos EUA em datas e horrios estabelecidos pelas mesmas. A no participao, mau comportamento, atrasos, entre outros, podero acarretar em meu desligamento imediato do programa, aplicando-se as regras de cancelamento. 9. Farei meu melhor no desempenho da tarefa de cuidar das crianas e todo o esforo para agir com carinho, responsabilidade e obedecer s regras da famlia anfitri em que vou viver. 10. Entendo que receberei um dos documentos necessrios para o visto DS 2019 em data estabelecida pela organizao. Caso queira solicitar o envio com prioridade ou precise solicitar um novo DS 2019 (em caso de perda, ou digitao errada de meus dados no application online, por exemplo) serei responsvel pelo custo de USD 50,00. 11. Concordo que a data de meu embarque, bem como a empresa area definida pela organizao AupairCare. Entendo ainda, que sou responsvel pela multa de USD 500 em caso de alterao da data de embarque, bem como eventuais multas decorrentes de alterao de vo por qualquer motivo, inclusive atraso na emisso do visto. 12. Obedecerei a todas as leis locais, estaduais e federais. Concordo em nunca pegar carona. 13. No comprarei, no terei em meu poder ou consumirei nenhuma droga controlada ou ilegal, exceto se prescrita por um mdico. No consumirei bebida alcolica se estiver abaixo da idade permitida. Se tiver idade legal para consumir bebida alcolica, no me excederei. Concordo em nunca dirigir aps ter consumido bebida alcolica. 14. As duas semanas de frias sero consideradas como 10 dias teis de frias remuneradas para gozar de comum acordo com minha famlia anfitri. As frias podem ser tiradas a partir do 3 ms no programa, com o mnimo de 1 (um) dia por ms. Se houver discordncia entre a famlia anfitri e a Au Pair sobre as frias, a AuPairCare resolver a questo, sendo sua deciso, a final sobre o assunto. 15. Entendo que serei responsvel por cuidar de crianas e por fazer tarefas domsticas relacionadas a elas. Isto corresponde superviso das crianas, preparo da comida, arrumao das camas e do quarto, lavagem das roupas e estar presente enquanto as crianas dormem. Entendo que minhas responsabilidades no incluem tarefas domsticas pesadas, ou qualquer outra tarefa domstica no relacionada s crianas. Se surgir
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Condies Gerais
AuPairCare - 2011
desentendimento entre a famlia anfitri e a Au Pair sobre suas responsabilidades, a AuPairCare ter a deciso final sobre o caso. 16. Concordo que se houver um beb com menos de 3 (trs) meses na famlia anfitri, um dos pais ou outra pessoa responsvel dever estar presente o tempo todo e, que no serei responsvel sozinha pela criana. 17. Entendo que se houver um beb com menos de 2 (dois) anos na famlia anfitri, devo ter experincia comprovada de, no mnimo, 200 horas de trabalho com faixa etria abaixo dos 2 (dois) anos. 18. Entendo que se tiver ou que me for permitido dirigir o(s) carro(s) da famlia anfitri, minha famlia anfitri responsvel por providenciar seguro de carro com um mnimo de US$10,000 (dez mil) de cobertura para despesas mdicas. Entendo que no serei responsvel em reembolsar mais do que US$250 (duzentos e cinqenta) por acidente. Concordo em nunca usar o(s) carro(s) da famlia anfitri sem expressa permisso deles. 19. Entendo que se for esperado que eu dirija ou se me for permitido guiar o(s) carro(s) da famlia anfitri, terei que ter carta de habilitao internacional antes de ir para os Estados Unidos. 20. Concordo em me matricular e freqentar uma escola/instituio (por um mnimo equivalente a 6 (seis) horas crdito. Entendo que meu curso deve acontecer em horrios mutuamente acordados entre eu e minha famlia anfitri. Entendo ser responsabilidade de minha famlia anfitri pagar at US$500/ano (quinhentos) pelo meu curso. E ser minha responsabilidade arcar com eventual diferena no curso que escolher. Entendo que este valor disponibilizado pela minha famlia, US$500 (quinhentos), dever ser utilizado nica e exclusivamente para realizao do curso escolhido. Do mesmo modo entendo que por qualquer razo, opte em no utilizar a passagem area de retorno provida pela Aupaircare, nenhum reembolso, crdito ou voucher de viagem ser provido. 21. Entendo que sou responsvel por pagar as despesas que fizer como e no limitado a - contas de telefone, despesas com o carro(s), despesas de viagem, e/ou despesas com sade que no forem cobertas pelo seguro. Se eu for embora da casa da famlia anfitri sem pagar as contas pendentes, a AuPairCare encaminhar minhas pendncias financeiras para que sejam quitadas .
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Condies Gerais
AuPairCare - 2011
22. Concordo em sair dos Estados Unidos, assim que terminar o programa. Entendo que se permanecer no pas alm da data permitida estarei infringindo seriamente as leis de imigrao. 23. Concordo em no estabelecer nenhum tipo de contrato enquanto estiver no programa, sendo de negcios, de trabalho, de casamento ou religioso. 24. Entendo que qualquer deciso sobre o meu status no programa, nica e desligamento, ou re-colocao, ser feita pela AuPairCare exclusivamente. 25. Concordo que na eventualidade de doena, acidente que me impea de continuar executando minhas tarefas, segundo julgamento da AuPairCare, terei que me desligar do programa e retornar ao Brasil. Concordo ainda a informar a AuPairCare eventual gravidez durante o programa . Neste caso, tambm serei desligada do programa e retornarei imediatamente ao Brasil. 26. Concordo em participar de todos os encontros mensais e atividades organizados pelos coordenadores da AuPairCare. Notificao de Problemas e Resoluo 1. Como a Au Pair est vivendo como um membro da famlia anfitri e no sob monitorao constante da AuPairCare, responsabilidade da Au Pair avisar a AuPairCare de qualquer problema significante, incluindo e no limitado a, sade, segurana, ou bem estar, adaptao na famlia, cultura, idioma, etc. 2. A Au Pair deve notificar a AuPairCare de todo desentendimento ou problema com a famlia anfitri. A AuPairCare intervir e tentar resolver o problema. A Au Pair entende que a AuPairCare exige um perodo de adaptao de 60 dias, aps a chegada nos Estados Unidos, antes que qualquer mudana possa ser considerada, entretanto, qualquer deciso sobre mudar ou no uma Au Pair de casa de famlia de nica e exclusiva deciso da AuPairCare. 3. Se a Au Pair no fizer esforo verdadeiro em prol da resoluo dos problemas ou desentendimentos, ou se a Au Pair violar quaisquer das regras destas Condies Gerais, a AuPairCare pode, por sua nica e exclusiva deciso, desligar a Au Pair do programa obrigando-a a voltar ao Brasil e pagar por sua despesa de retorno, incluindo a passagem area, etc. 4. A Au Pair responsvel em desempenhar todas suas funes satisfatoriamente, incluindo a comunicao em ingls com a famlia. A AuPairCare decidir em caso de contratempos em relao ao nvel de ingls na comunicao , se a Au Pair seria recolocada ou desligada do programa,
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Condies Gerais
AuPairCare - 2011
retornando ao Brasil sem direito a reembolsos e com o custo da passagem area de retorno. 5. No caso da Au Pair no completar, com sucesso, o programa de 12 meses, a Au Pair responsvel por custear a despesa com sua viagem de volta ao Brasil, incluindo a passagem area. 6. No caso da primeira colocao da Au Pair no ser de sucesso e a AuPairCare decidir, por sua nica e exclusiva liberalidade, que h necessidade de recolocao , a Au Pair concorda em colaborar com a AuPairCare durante todo o processo de recolocao. Se a AuPairCare no conseguir fazer a mudana da famlia durante um perodo de 14 (quatorze) dias, a Au Pair poder ser enviada de volta ao Brasil tendo que arcar com todas as despesas da viagem de retorno, incluindo a passagem area. 7. Caso a famlia anfitri desejar hospedar a Au Pair durante o perodo de transio at que uma nova colocao acontea e a AuPairCare decida, por sua nica e exclusiva liberalidade, que diante das circunstncias isto plausvel, mas a Au Pair no concordar com tal deciso, a Au Pair ter que pagar US$25 (vinte e cinco) por dia para a casa de famlia temporria que dever ser de coordenadores da AuPairCare. Preos USD 740 sendo, Taxa Administrativa Inscrio: Taxa de Participao: USD 190 (pagar no ato da inscrio) USD 550 (pagar na confirmao da famlia)
________________________________________________________________________________ Validade dos preos Se por qualquer motivo, os prazos estipulados no sejam cumpridos, sero aplicados os preos atualizados, caso haja alteraes. Forma de Pagamento Ao receber o application CI, a participante paga o equivalente a USD19 USD190 190 (Taxa Administrativa); Caso o pagamento da Taxa de Participao seja parcelado no carto de crdito, a Au Pair dever iniciar o pagamento da mesma no ato da inscrio. No ser permitido o parcelamento no ato da confirmao da famlia;
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Condies Gerais
AuPairCare - 2011
Caso a opo de pagamento seja a vista, o pagamento da taxa de participao dever ser feito em at 48 horas quando acontecer a aceitao mtua da famlia hospedeira e participante e, portanto, a Au Pair j tiver sua colocao definitiva nos USA, Regras de Cancelamento Os USD190 (cento e noventa) da taxa Administrativa no so reembolsveis em quaisquer circunstncias. Se a participante cancelar o programa antes de acontecer sua colocao numa casa de famlia americana, perde os USD190 (cento e noventa) da taxa Administrativa. Se a participante cancelar o programa depois de sua colocao numa famlia anfitri, a multa ser de USD 540 (Taxa Administrativa + Taxa cancelamento CI USD 50 (cinqenta) + Taxa de Cancelamento AuPaircare USD 300), e ainda, eventuais multas da passagem area, a ser informado pela organizao americana. Se a participante cancelar o programa devido a visto americano negado, haver multa de USD490 (Quatrocentos e noventa - Taxa Administrativa + Taxa de Cancelamento de USD 300 (trezentos)) e ainda, eventuais multas da passagem area, a ser informado pela organizao americana. Se a participante desistir do programa, aps sua chegada nos USA, no h reembolso de nenhum do valor pago, e a au pair ter que arcar com sua passagem area de retorno imediato. Solicitao de Reembolso As solicitaes de reembolso devero ser feitas por escrito, mediante apresentao de carta com informaes bancrias para depsito. No caso de visto negado, o DS-2019 dever ser retornado em perfeitas condies no prazo de 1 semana com comprovao do visto negado. Tais solicitaes sero analisadas conforme critrios acima e providenciadas, exclusivamente para depsito em conta bancria. O reembolso ser analisado e efetuado pela menor taxa de cmbio, na qual comparada entre a taxa do dia do recebimento com a taxa do dia do pedido do reembolso, o que for menor do recebimento do da Taxa de Participao, no prazo de 90 dias, a contar do recebimento da solicitao de reembolso pela CI.
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Condies Gerais
AuPairCare - 2011
Para os casos de parcelamento sem juros no carto o reembolso ser realizado atravs do cancelamento do carto e crdito disponibilizado no mesmo. Aspectos Gerais Como condio da participao da Au Pair no programa, as Au Pairs concordam em isentar a AuPairCare/CI de qualquer dano, atraso ou despesa que ocorra por (i)qualquer incidente de fora maior que no possa ser controlado pela AuPairCare/CI, incluindo e no limitado a, fenmenos naturais, do governo e restries, (ii)quaisquer eventos direto ou indiretamente causados, parcial ou totalmente, por atos de negligncia ou intencionais ou emisso de uma 3 parte, incluindo, mas no limitado a, qualquer membro, hspede, empregado ou agente da famlia anfitri, ou quaisquer outras pessoas nos Estados Unidos, mesmo que seja alegada negligncia da Au Pair como contribuio ao fato, (iii) riscos associados com viagem e vivncia internacional, incluindo, mas no limitado a riscos associados a tratamento de sade, condies de vida, condies sanitrias, sistema de transporte e estradas, sistema de justia criminal, leis de liberdade civil, costumes e valores, (iv) qualquer diferena nas condies de vida e padro da casa brasileira com as da casa americana. Como mais uma condio para a participao da Au Pair no programa, a Au Pair no responsabilizar a AuPairCare/CI judicialmente ou financeiramente, incluindo custos de advogado e justia, resultados de qualquer ocorrncia, perda ou qualquer dano ou despesa causado pela Au Pair durante sua participao no programa. Concordo que a AuPairCare/CI , sem nus ou despesa para as empresas, tomem qualquer ao que achem necessria em prol de minha sade e segurana e podem me colocar num hospital, ou se este no estiver disponvel, me encaminhar para as mos de um mdico local para tratamento. O seguro mdico vlido por 365 dias, a partir de minha chegada nos Estados Unidos e entendo que devo pagar uma taxa de extenso para receber cobertura aps este perodo. Atesto que as informaes por mim fornecidas no dossi (application form) so verdadeiras e, concordo que desenvolverei minhas obrigaes como Au Pair fazendo o meu melhor. Li toda estas Condies Gerais, tive oportunidade de fazer perguntas, obter orientao e entendi tudo. Sou capaz de entender, estou ciente e concordo com o AuPairCare Au Pair Agreement - Condies Gerais em ingls a qual assinei. No vou confiar em nenhum testemunho, promessas
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Condies Gerais
AuPairCare - 2011
Condies Gerais ou AuPairCare Au Pair Agreement - Condies Gerais em ingls. Mantenho uma cpia destes documentos. DECLARAO Eu, ________________________________________________________ declaro entender, estar ciente e de acordo com as Condies Gerais apresentadas em 7 pginas, bem como declaro entender e estar de acordo com as informaes contidas no AuPairCare Application e Agreement em idioma ingls parte integrante do mencionado Condies Gerais. Para dirimir qualquer dvida na execuo e interpretao do presente ajuste, no resolvida entre as partes, fica eleito o foro da Cidade de ______________________________________________ .
Nome:____________________________________________________________
Assinatura:_______________________________________________________
Local e Data: ______________________________________________________ Informaes Complementares: 1- Nos informe o nmero de sua camiseta para embarque: Camiseta: ( )P ( )M ( )G
2- Voc aceita que seu email seja encaminhado para as outras participantes do programa Au Pair? ( ) Sim ( ) No
3- Informe as datas (primeira e ltima) disponveis para o embarque: ___/___/____ at ___/___/____.
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10
AuPairCare Au Pair Agreement

(rev. 10/2010)
This AuPairCare Au Pair Agreement (the Agreement) is entered into between AuPairCare, a California Corporation and Au Pair (first and last name of Au Pair) ____________________ _____of (City) ______________________, (Country) __________________. Au Pair has fully read this Agreement and agrees to the terms and conditions contained herein. Host Family is the family in the United States with whom Au Pair has agreed to match, and with whom Au Pair will live and work. A. General Provisions Au Pair is hereby advised and acknowledges that the parties agree as follows: 1. Au Pair will abide by the terms and conditions of this Agreement for the duration of Au Pairs participation in the AuPairCare program, unless and until this Agreement is replaced or modified by a subsequent written agreement executed by AuPairCare and Au Pair. Au Pair is hereby advised and acknowledges that all Au Pairs are participants in a cultural exchange program, and agrees to comply with all of the regulations published by U.S. Department of State in 22 CFR Part 514, as the same may be amended from time to time in the future (the Regulations). Said regulations can be found by visiting: http://exchanges.state.gov/jexchanges/index.html. Au Pair represents that all information provided throughout the application process is true and that no relevant information has been excluded or misrepresented in the application process and documents, including representation of the level of English proficiency, health and/ or childcare experience. Au Pair agrees that all such disclosures will be full and accurate, up to and through the date of departure from Au Pairs country of origin. Au Pair agrees to complete all visa screening requirements in accordance with the instructions given and will be responsible for obtaining a valid passport and complying with all vaccinations and immunization requirements. Au Pair agrees to immediately amend any disclosures should new information become available to Au Pair in any regard or at any time of participation in the program. Au Pair represents that s/he will personally conduct all written and phone correspondence with Host Family during the interviewing process. Au Pair understands that exaggeration or falsification of any application information by Au Pair, references or Originating Exchange Organization may result in immediate dismissal from the program and return to Au Pairs home country at Au Pairs expense. AuPairCare has the exclusive right to determine suitability of Au Pair to participate in the program both before and during participation in the program. Au Pair agrees that in determining suitability, AuPairCare may make inquiries to third parties about Au Pair, including but not limited to medical personnel and insurance agencies otherwise covered by federal HIPAA regulations. Au Pair is not an employee, agent or independent contractor of AuPairCare, and AuPairCare does not exercise dominion or control over the actions of the Host Family. B. Fees and Program Costs 8. 9. Participation in the AuPairCare program requires Au Pair to pay a non-refundable program fee in the amount of US $____________. Originating Exchange Organization may charge Au Pair additional fees to cover their administrative costs in promoting the AuPairCare program and processing au pair applications. The fees may include, but are not limited to, an application fee, processing fee, handling fee, and interview fee. These fees may vary
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across Originating Exchange Organizations. AuPairCare assumes no duties or responsibilities for any acts or omissions of the Originating Exchange Organization regarding additional fees. 10. Au Pair will be responsible for additional costs, including but not limited to, baggage check fees for arrival and return flights, personal expenses while at the Au Pair arrival orientation, medical expenses not covered by insurance and all incidentals and personal expenses while on the program. Au Pairs should be prepared to cover these costs. 11. Au pair will pay all applicable fees to Originating Exchange Organization before beginning travel to this United States. Au Pair may not under any circumstances solicit funds from Host Family for to cover personal costs of program, including but not limited to fees due to the Originating Exchange Organization, costs associated with securing a visa, or incidental travel costs. 12. Au Pair agrees that s/he has adequate financial resources to satisfy all obligations as an AuPairCare Au Pair, including payment for a return flight if Au Pair does not successfully complete the program. C. Au Pair Cancellations/Flight Change Requests 12. Au pair agrees to pay a $300.00 USD cancellation fee, plus the actual cost of international and/or domestic airfare (if travel has been arranged), in the event he/she cancel from the program after matching with a family but prior to arrival at the host family home. 13. Au pair agrees to pay a $300.00 USD change fee and any applicable airfare penalties, in the event he/she requests to change their arrival date. D. Responsibilities 14. Au Pair understands that during the first three (3) days of an au pairs stay in the home, a parent or another responsible adult shall remain in the home to facilitate the adjustment of the au pair into the family, household and community. 15. Au Pair agrees to perform childcare services and light housekeeping related to childcare that shall not exceed forty-five (45) hours per week, five and one half (5 1/2) days per week, with a maximum of ten (10) hours per day. Au Pair will have one full weekend off per month (Friday evening to Monday morning). If a dispute arises as to any of these limits or requirements, AuPairCare shall resolve said dispute, and its decision shall be final. 16. Au Pairs responsibilities will be limited to childcare and child-related tasks for the Host Family. This may include duties such as general supervision, preparing and cleaning up after childrens meals, straightening childrens rooms, doing childrens laundry, preparing the children for school, assisting with homework, and being present when children are sleeping. The Au Pairs responsibilities will not include heavy housework, yard work or other non-child related labor for the household. If a dispute arises concerning the scope of the Au Pairs responsibilities, AuPairCare shall resolve said dispute, and its decision shall be final. 17. Au Pair understands that U.S. Department of State regulations prohibit Au Pair employment beyond the au pair arrangement with the Host Family. Au Pair may not undertake any other paid work while in the U.S., including babysitting for Host Family for extra pay beyond the 45 hour weekly limit, babysitting for other families, or tutoring language students. 18. Au Pair is hereby advised and understands that if there is an infant under the age of two years old in the household, the au pair must have 200 hours of documented experience working with children under the age of two. Such documented experience shall be verified by AuPairCare prior to au pair placement. 19. Au Pair understands that in the event there is an infant under the age of three months in the household, a parent or other responsible adult shall be present in the home at all times, and Au Pair shall not be the sole caregiver for that child at any time. 20. Au Pair agrees to perform the childcare responsibilities to the best of his/ her ability, and make every effort to act as a caring, responsible Host Family member.
Au Pair Agreement Page 2 of 8 Rev 10/2010
E. Behavior and Comportment 21. Au Pair agrees to abide by Host Family rules as they are determined by the Host Family, and will behave as a responsible member of the Host Family at all times. If a dispute arises concerning the Host Family rules, AuPairCare shall resolve said dispute, and its decision shall be final. Au Pair understands that Host Family is not required to provide access to a car, personal phone line, personal television, computer or other perks. 22. If Au Pair is expected or permitted to drive the family car(s), Au Pair will obtain a valid international drivers license prior to arrival in the United States, and if required by law, obtain a U.S. drivers license at his/her own expense. Failure to do so may result in termination from the program. Au Pair understands that if s/he is expected or permitted to drive the family car(s), the Host Family must provide sufficient automobile insurance to comply with all applicable laws, and which insurance shall in no event cover less than $10,000 in medical coverage. Au Pair will not be responsible for payment of any automobile insurance deductibles that exceed $250 per accident. Au Pair agrees never to use the car(s) without the express permission of Host Family or to use the car for purposes not approved by the Host Family. 23. Au Pair agrees not to hitchhike at any time, due to the dangerous nature of hitchhiking in the United States. 24. Au Pair agrees to exercise sound judgment and caution while participating in Internet-based communities and social networking websites such as Facebook, Orkut, MySpace or other sites. Au Pair understands that Host Family information, including but not limited to phone numbers, addresses, family names, information about Host Family children, or photos of Host Family home and household members may not be posted online by Au Pair, without the Host Familys prior consent. 25. Au Pair agrees not to buy, possess or consume any controlled or illegal substances, except those prescribed by a physician. Au Pair understands that the legal drinking age in the United States is age 21, and that the legal ramifications of underage drinking in the United States are serious and can result in immediate termination from the AuPairCare program. Au Pair agrees not to consume alcoholic beverages at any time if Au Pair is under the legal drinking age of 21. If Au Pair is of legal drinking age, Au Pair agrees not to excessively consume alcoholic beverages at any time. Au Pair agrees never to drive an automobile after consuming alcoholic beverages. Au Pair agrees never to consume alcoholic beverages while on duty caring for Host Family children. As with all other terms of this Agreement, if Au Pair violates this term of the Agreement, AuPairCare may in its sole discretion terminate Au Pairs participation in the program and immediately repatriate Au Pair to his/her home country at Au Pairs expense. 26. Au Pair agrees to abide by all local, state and federal laws. If Au Pair is arrested and/or is in police custody under suspicion of committing a crime, AuPairCare will not arrange or pay for legal assistance or representation for Au Pair. Au Pair will be responsible for resolving any legal matters independently and without the assistance of AuPairCare and its staff. As with all other terms of this Agreement, if Au Pair violates this term of the Agreement, AuPairCare may in its sole discretion terminate Au Pairs participation in the program and immediately repatriate Au Pair to his/her home country at Au Pairs expense. 27. Au Pair understands that the AuPairCare program is a smoke free program and agrees not to smoke while participating in the AuPairCare program. This includes, but is expressly not limited to, smoking in or around the Host Family home. As with all other terms of this Agreement, if Au Pair violates this term of the Agreement, AuPairCare may in its sole discretion terminate Au Pairs participation in the program and immediately repatriate Au Pair to his/her home country at Au Pairs expense. F. Compensation and Financial Responsibility 28. Au Pair will receive room and board in the form of meals and a suitable private bedroom in Host Familys home, which has been approved by a local AuPairCare representative. 29. Au Pair will receive a weekly stipend in accordance with the U.S. Department of State Regulations in the amount of $195.75. Said stipend shall be paid by the Host Family on the same mutually agreed upon day each week in the payment method chosen by the Host Family, and cannot be withheld for any reason.
30. Au Pair will receive two calendar weeks paid vacation (10-days), to be taken at mutually agreed upon times. Vacation days shall accrue on the basis of one day per month from the beginning of Au Pairs third month in the U.S. During Au Pair's extension program, Host Family will provide 9-month and 12month extension Au Pair with two calendar weeks (10-days) of paid vacation, to be taken at mutually agreed upon times. A 6-month extension Au Pair will receive one calendar week (5-days) of paid vacation. Vacation days shall accrue on the basis of one day per month from the beginning of the Au Pairs thirteenth month in the U.S. If any disputes arise concerning vacation issues, AuPairCare shall resolve said dispute, and its decision shall be final. 31. Au Pair understands that he/she is not entitled to paid or unpaid holiday time-off. 32. Au Pair will receive subsidy of educational costs from the Host Family as outlined in the Training and Education Requirements section of this document. 33. Upon successful completion of the program, Au Pair will receive a return flight airline ticket from AuPairCare to Au Pairs home country. Au Pair will be responsible for planning and paying for travel from the international destination airport to Au Pairs final destination in home country. Au Pair understands that in the event Au Pair does not elect to use the return air ticket provided by AuPairCare for any reason, no refund, credit, or travel voucher will be provided. 34. Au Pair understands that in 1994, the U.S. Department of Labor determined that the au pair stipend constitutes "wages" because an employer-employee relationship exists between the au pair and the Host Family. Au Pairs wages are essentially in the nature of household employment, and therefore Au Pair is required to file U.S. individual tax returns, even if no taxes are due. 35. Au Pair is responsible for complying with any Federal or state labor and/or income tax laws that may apply to Au Pair. AuPairCare does not provide legal advice regarding any such laws and is not responsible for informing Au Pair of, or overseeing compliance with, any such labor laws, including but not limited to Workers Compensation laws and/or income or other tax laws which may vary from state to state, and are subject to change from time to time. 36. Au Pair is wholly responsible for personal expenses and management of personal finances. AuPairCare shall not be responsible for any personal bills incurred by the Au Pair or Host Family, such as (without limitation) telephone bills, automobile expenses, travel expenses, and/or health expenses not covered by insurance. Accordingly, Au Pair agrees not to seek payment or assistance in recovering any such expenses or costs from AuPairCare. G. Travel and Accident Insurance 37. Au Pair will receive travel and accident insurance provided by AuPairCare through a third-party insurance carrier, and such coverage contains limitations and exclusions. Au Pair agrees to review the scope of said coverage and the limitations and exclusions contained therein prior to arrival in the United States. Said information can be accessed on AuPairCares website, www.aupaircare.com. Au Pair is advised and agrees that any disputes pertaining to coverage issues are strictly between Au Pair and the third-party insurance company, and agrees that AuPairCare is not responsible for any coverage issues and/or disputes. 38. Au Pair understands that pre-existing medical conditions will not be covered by the third-party travel and accident insurance. 39. Au Pair understands that the dental insurance provided to them only covers injuries that are the result of an accident, and does not cover the cost of standard dental treatment. It is therefore important for Au Pair to receive a thorough dental examination so that no unexpected complications arise during the period of residence abroad. 40. Au Pair represents that the medical history provided to AuPairCare is true, and gives full consent to release all medical and psychiatric history information to potential host families. 41. If Au Pairs medical condition changes (including pregnancy), between the time of signing this document and Au Pairs departure to the U.S., Au Pair understands that s/he is required to notify AuPairCare and resubmit another Physician Verified Medical History document prior to arrival. As with all other terms of this Agreement, if Au Pair violates this term of the Agreement, AuPairCare may in its sole
discretion terminate Au Pairs participation in the program and immediately repatriate Au Pair to his/her home country at Au Pairs expense. 42. Au Pair agrees that AuPairCare and/or its affiliates or agents may, without liability or expense to themselves, take whatever action they deem appropriate with regard to Au Pairs health and safety, including, but not limited to having Au Pair hospitalized for medical services and treatment. Au Pair further agrees that if hospitalization is not feasible for any reason, AuPairCare and/or its affiliates or agents may rely upon the advice and medical judgment of local medical staff in order to make a decision as to what is in Au Pairs best interests. Au Pair hereby gives full consent to be medically treated pursuant to the terms of set forth herein, and/or to undergo any treatment, including but not limited to surgery, which is determined to be necessary to Au Pairs health and well-being during Au Pairs stay abroad. 43. Insurance provided by AuPairCare is valid for 365 days from Au Pairs arrival in the US and Au Pair accepts responsibility for payment of an extension fee to receive any coverage after the 365 days. 44. Au Pair accepts full responsibility for any medical expenses which are not covered by the insurance policy provided by AuPairCare through a third party. 45. In the event Au Pair displays a serious medical condition that in the judgment of AuPairCare prevents the Au Pair from continuing in the program (including but not limited to mental illness, substance abuse, eating disorders and/or pregnancy), whether said condition is pre-existing or new, Au Pair will be terminated from the au pair program at AuPairCares sole discretion. H. Training and Education Requirements 46. Au Pair agrees to complete 32 hours of training prior to arrival at Host Family home, as required by the United States Department of State. To meet this requirement, Au Pair will attend in full the Au Pair Academy training program upon arrival in the United States and complete a required PreDeparture Project as defined by AuPairCare. 47. Au Pair understands that all 12-month program Au Pairs are required to attend courses of study at an accredited U.S. post-secondary institution for a minimum of six (6) credit hours or its equivalent in credit hours. Host Family will provide Au Pair with time off and provide adequate transportation to and from the place of instruction, and will pay tuition up to a maximum of $500 per au pair per year. Local AuPairCare Area Directors are available to provide information about this requirement and acceptable schools; however, it is Au Pairs responsibility to plan appropriately so that s/he is able to fulfill the requirement. 48. Au Pair understands that all courses shall be taken at mutually agreed upon times with the Host Family. Au Pair shall be responsible for costs associated with such educational study that exceed the amount paid by Host Family. Au Pair agrees to submit an Education Plan at the start of the program year to outline coursework plans. Au Pair agrees to provide documentation of coursework completion towards the end of the program year. In the event Au Pair does not complete the educational requirement, Au Pair will be ineligible to apply for an extension of the au pair program. I. Extension of Au Pair Program 49. Au Pair is hereby advised and understands that au pairs wishing to participate on the Extension Program must submit their application on or before AuPairCares published deadline date and AuPairCare does not guarantee that AuPairCare or the Department of State will approve any extension request or that au pairs who choose to self-extend will match with a new Host Family. 50. Au Pair is hereby advised and understands that au pairs participating on the extension program will receive an updated DS-2019 form that reflects the 6, 9, or 12-month program extension. Although au pairs will have a valid DS-2019 form, the J-1 visa in his/her passport may have expired during the first 12-months of stay in the U.S. Any travel outside the U.S. is at the au pairs own risk, and AuPairCare cannot assist Au Pair or Host Family in resolving any visa concerns they may encounter. 51. Au Pair understands that Extension Au Pairs are required to repeat the educational component of the program during the extension time as follows: The educational component for a 6-month extension is not less than three (3) semester hours of academic credit or its equivalent. Host Family will contribute up to $250 toward the educational component. The educational component for a 9 and 12-month extension
is not less than six (6) semester hours of academic credit or its equivalent. Host Family will contribute up to $500 toward the educational component. J. Problem Resolution and Placement Changes 52. Au Pair is living as a member of a Host Family and is not under continual oversight or control of AuPairCare staff. Therefore, it is Au Pairs responsibility to promptly advise AuPairCare of any significant problems or events that occur during the program, including but not limited to Au Pairs health, safety, welfare, or adjustment to family, culture, or languages. For purposes of this Agreement, a significant event or problem is any change in Au Pairs circumstance that may affect an au pairs well-being and/or living situation. 53. Au Pair is hereby advised and understands that AuPairCare requires an initial adjustment period of 60 days following Au Pairs arrival before any placement change is considered; however, any decision regarding Au Pair removal is at AuPairCares sole discretion and can be made at any time. 54. Au Pair should notify the local AuPairCare representative of any misunderstandings or problems with the Host Family if they persist after Au Pair has tried to address them with Host Family. AuPairCare will work with both Au Pair and Host Family to attempt to resolve the problem before authorizing a placement change. Au Pair must show a sustained good faith effort to resolve the issues with Host Family before AuPairCare will approve an Au Pairs request for a placement change. If Au Pair does not make a good faith and substantial effort to resolve the problems or misunderstandings with Host Family, or if Au Pair violates any terms of this Agreement, AuPairCare may in its sole discretion terminate the Au Pairs participation in the program and immediately repatriate Au Pair to his/her home country at Au Pairs expense. 55. Au Pair understands that the nature of the au pair program is one of flexibility and cultural exchange, and that placement changes may not be requested in order to achieve a preferred work schedule, location, or perks provided by Host Family. Once Au Pair agrees to match with a Host Family, Au Pair has in effect agreed to that Host Familys required schedule, location and benefits provided by the Host Family to Au Pair. Au Pair agrees to remain flexible in order to continually meet Host Family needs as they evolve over the course of the program year. Changes in Host Family needs do not constitute grounds for Au Pair to request a placement change. 56. In the event Au Pairs first placement is not successful, and AuPairCare determines in its sole judgment that Au Pair shall be placed in a new family, Au Pair agrees to cooperate with AuPairCare during the entire re-matching process, including but not limited to ensuring that potential new Host Families can easily reach Au Pair by e-mail and phone in a timely manner to arrange interviews. Au Pair is hereby advised and agrees that a replacement Host Family will be provided at the sole discretion of AuPairCare and may be dependent upon current Host Family availability. A replacement Host Family may not be available. In the event that AuPairCare is unable to provide a replacement Host Family within 14 days from the end of the first placement, Au Pairs participation in the program will end and Au Pair will have to return home at his/her personal expense. 57. If the Host Family is willing to house Au Pair until she or he is re-matched, and AuPairCare, in its sole discretion, determines that under the circumstances it would be reasonable for Au Pair to remain in the home, but the Au Pair refuses to stay with the family, Au Pair will be required to pay a $25.00 per day housing stipend to the party who houses him/her, typically an AuPairCare field staff member. 58. If Au Pair leaves the host family home without notice to AuPairCare and/ or Host Family and does not contact AuPairCare within 24 hours from departure, Au Pair may be subject to dismissal from the program, and Au Pair may be immediately repatriated to his/her home country at Au Pairs expense. 59. In the event Au Pair does not successfully complete the program year, Au Pair is responsible for his/her return travel expenses. 60. AuPairCare is not responsible for any economic damage or loss alleged to arise from loss of or unavailability of a replacement Host Family. 61. Au Pair agrees that any decision regarding an au pairs program status, dismissal, or re-placement will be made at the sole discretion of AuPairCare, and said decisions shall be considered final.
62. In the event of accident or serious illness or medical condition that, in the judgment of AuPairCare, prevents Au Pair from continuing her/his duties, she/he will end the program early and return home. K. Other Terms and Conditions 63. Au Pair agrees to leave the United States within 30 days of the conclusion of his/her program. Au Pair understands that any stay beyond the 30-day grace period is a direct breach of the Regulations of the Department of State, and that Au Pairs future ability to travel, work or live in the United States may be compromised. 64. Au Pair agrees not to enter into any kind of contractual agreement during the program year in the United States, including but not limited to business, employment, marital or religious contracts. 65. Au Pair understands that if he/she is terminated or voluntarily leaves the program for any reason, they are not eligible for the 30-day grace period benefit and must depart the United States immediately. 66. Au Pair consents and authorizes AuPairCare to use Au Pairs name, photographs, file, application content, video resume (video CV), or video likeness of Au Pair or any comments or statements from host in materials or publications to promote the AuPairCare program. 67. Au Pair understands that AuPairCare is not a party to any agreement between Au Pair and the Originating Exchange Organization located in Au Pairs home country (Originating Exchange Organization). Au Pair acknowledges and agrees that the Originating Exchange Organization is solely responsible to Au Pair for injury or damage from a violation of any such agreement. AuPairCare assumes no duties or responsibilities for any acts or omissions of the Originating Exchange Organization. 68. Au Pair agrees not to post any Host Family personal information, images or video online or in publicly accessible areas at any time, including before, during or after duration of official program year, without the Host Familys prior consent. 69. Au Pair understands that AuPairCare will make its best, reasonable and diligent efforts at locating and screening all Host Families. Au Pair agrees to assume the risks involved in the matching with a Host Family, and hereby irrevocably, unconditionally, and fully waives, releases and forever discharges AuPairCare, its subsidiaries, officers, employees, and/or agents from any and all claims related to personal and/or property damage, injury, loss, delay or expense incurred by Au Pair or any guest, employee or agent, due to: (i) events beyond AuPairCares reasonable control, including without limitation acts of God, acts of war or government actions or restrictions. (ii) any events and/or acts directly or indirectly caused by any intentional or negligent acts or omissions at any time, in whole or in part, by any Au Pair and/or Host Family or by any third party, including but not limited to any member, guest, employee or agent of the Host Family or other persons in the host country, even if AuPairCares negligence is alleged to have contributed to the event, (iii) risks associated with foreign travel and living abroad, including but not limited to risks associated with health care services, living conditions, sanitation conditions, road and transportation systems, criminal justice systems, civil liberty laws, customs and values, (iv) any differences in the living conditions and standards between Au Pairs home and home country and the host home and host country, and, (v) any act or omission of the Originating Exchange Organization. In this respect, Au Pair acknowledges that neither Host Family nor Au Pair are an employee or agent of AuPairCare and actions or omissions of Au Pair or Host Family are not to be attributed in any way to AuPairCare. Au Pair fully agrees to assume all such risks and agrees to indemnify and hold harmless AuPairCare, its subsidiaries, officers, employees and/or agents for any liability or expense, including court costs and legal fees incurred, that Au Pair has in any way caused or contributed to, whether directly or indirectly, and whether intentionally or unintentionally.
70. This Agreement shall be deemed to have been made in the State of California, U.S., and its validity, construction, breach, performance and interpretation shall be governed by the laws of the State of California, U.S. 71. The parties to the Agreement acknowledge and agree that any dispute or claim arising out of this Agreement, including but not limited to any resulting or related transaction or the relationship of the parties, shall be decided by neutral, exclusive and binding arbitration in San Francisco, California, U.S. before an arbitration provider selected by AuPairCare, upon the petition of either party. In such proceeding, the parties may utilize subpoenas and have discovery as provided in California Code of Civil Procedure Sections 1282.6, 1283 and 1283.05. The decision of the arbitrator shall be final and binding and may be enforced in any court of competent jurisdiction. Au Pair agrees that California is a fair and reasonable venue for resolution of any such dispute and it submits to jurisdiction of the Courts of the State of California because, among other reasons, this agreement was negotiated in large part in California, and AuPairCare is domiciled in California. In the event that the arbitration clause is deemed void or inapplicable, each party expressly consents to and submits to the personal jurisdiction of the federal or state court(s) of San Francisco County, California, U.S. In any action, including arbitration, brought for breach of this Agreement, the prevailing party shall be entitled to recover reasonable attorneys fees and costs, including but not limited to the costs of arbitration 72. If there are any differences between this Agreement and any other program materials, this Agreement shall control. AuPairCare cannot be legally bound or committed by any person other than a duly authorized representative. Parties are required to follow this Agreement and cannot vary from its terms. 73. An electronic or facsimile signature on this Agreement shall be considered the same as an original. Please initial each of the below statements: ______ (initial) I promise that the information I have given in the application form completed by me is accurate, I have read this entire agreement carefully, and I have had the opportunity to ask questions, obtain advice as to its meaning, and I understand it. I am capable of reading and understanding this agreement in English. I do not rely on any promises, statements or representations that are not expressly stated in this Agreement. I have retained a copy of this Agreement for my files. ______ (initial) I agree to provide childcare services for my host family. I understand that my hours will not exceed forty-five (45) hours per week, for a maximum of ten (10) hours on any given day, over a period of five and one-half (5 ) days on a given week, and that I will have at least one (1) full weekend free each month, scheduled in advance. ______ (initial) My signature below indicates acceptance of the terms of this Agreement, and is legally binding. No alteration of the terms of this Agreement will be valid unless approved by AuPairCare in writing.
AU PAIR NAME (PRINT): __________________________________ AU PAIR NAME (SIGNATURE): _____________________________ DATE: _______________

Au Pair

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Documentos AuPairCare

Instrues de Preenchimento e Check list

ATENO: ENVIAR 02 (DUAS) VIAS DE CADA DOCUMENTO

ser enviados organizao internacional.

Slep Test (mnimo de 55 pontos)

Au Pair Application on line

Physician verified Medical History

2 Childcare References (portugus e ingls)

Character Reference (portugus e ingls)

Au Pair Agreement 2010

Structured Interview (entrevista realizada pela CI)

Au Pair Care Interview (entrevista feita pela loja CI)

Atestado de Antecedentes Criminais (1 via em portugus e 1 via em ingls).

Cpia da carteira de motorista

Cpia do passaporte (as duas primeiras pginas)

Condies Gerais CI assinada.

4. How would you describe this persons character?

Email Address: ____________________________ Evening Phone: (011) _______________________

For Office Use Only: Verified by: _________________________________________________________ Date: _____/_____/________

4. Como voc descreve a personalidade da candidata?

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8. Por favor liste as atividades e deveres durante este perodo:

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Physician Verified Medical History

Name of Patient: ____________________________________________ Age: ________________________ Height: _____________________

Date of Birth: _______/_______/_______ (month/day/year) Weight: _________________________________________

No If yes, please explain:

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Au Pair Signature: ___________________________________________________________________ Print Name: ___________________________________________________________________

Repeat Au Pair Questionnaire

Au Pair Match Information

Is the applicant willing to live with a single mother?

____________________________________________, ____________________________________, Brasil.

3- Informe as datas (primeira e ltima) disponveis para o embarque: ___/___/____ at ___/___/____.

AuPairCare Au Pair Agreement

Au Pair Agreement Page 2 of 8 Rev 10/2010

Au Pair Agreement Page 3 of 8 Rev 10/2010

Au Pair Agreement Page 8 of 8 Rev 10/2010

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