Host Family Application Form

I understand that by sending this application I have read and understood the Terms & Conditions and enter a legal agreement with Au Pair New Zealand. *

A copy of the terms & Conditions can be found here: https://bit.ly/2QoDJhf

I understand that Au Pair New Zealand will use my contact details for sending me updates through newsletters and that I can remove myself from the newsletter at any time. *

I understand that I need to provide Au Pair New Zealand with the documents as outlined below. *

The host family shall send the following documents to complete their application: 1.Application form, 2. recent pictures of the family and family home (esp. the au pair room), 3. a letter to the au pair, 4. a detailed working schedule incl. emergency numbers, 5. house rules, 6.a police check for anyone in the household who is 18 or older. Once an au pair is placed you also will send us a copy of your contract between yourself and your au pair.

Full name host mother *

Date of birth (DD/MM/YEAR) *

Nationality as shown on passport *

Occupation *

Interests & hobbies *

Address *

House number, street, location, postal code, county

Land line *

Mobile phone *

Email *

Skype ID *

Facebook ID / Instagram ID *

Follow us on social media: https://www.facebook.com/aupairnewzealand/ and https://www.instagram.com/aupairnz

Do you suffer (or have suffered) from a medical/mental health condition? *

Please note that your info will be treated confidential and that we will discuss this during our interview with you.

If yes, what condition (please elaborate)?

Have you ever been convicted for a crime? *

If yes, please elaborate

Have you applied for a copy of your criminal record? *

You are obliged to send us a copy of your criminal record before we can place an au pair in your family. A form can be obtained here: https://www.justice.govt.nz/criminal-records/get-your-own/

Date you submitted the application (DD/MM/YEAR)

Full name host father *

Date of Birth (DD/MM/YEAR) *

Nationality as shown on passport *

Occupation *

Interests & hobbies *

Address (if different than the above) *

House number, street, location, postal code, county

Land line (if different from the above) *

Mobile phone *

Email *

Skype ID *

Facebook ID / Instagram ID *

Follow us on social media: https://www.facebook.com/aupairnewzealand/ and https://www.instagram.com/aupairnz

Do you suffer (or have suffered) from a medical/mental health condition? *

Please note that your info will be treated confidential and that we will discuss this during our interview with you.

If yes, what condition (please elaborate)?

Have you ever been convicted for a crime *

If yes, please elaborate

Have you applied for a copy of your criminal record? *

You are obliged to send us a copy of your criminal record before we can place an au pair in your family. A form can be obtained here: https://www.justice.govt.nz/criminal-records/get-your-own/

Date you submitted the application (DD/MM/YEAR) *

Full name child 1 *

Date of birth (DD/MM/YEAR) *

Does your child *

What are the child's interests & hobbies *

Has your child a special need (disability, allergy, medication) *

If yes, what type of special need and what do you expect from the au pair *

Please note that the au pair is not a trained child carer and that they shall not perform duties that require special childcare skills.

Full name child 2 *