AuPairCare

Host Family ID#*

Host Family Last Name

Host Family First Name

Host Family Address

Host Family City

State Please Choose Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Host Family Zip Code

Your Last Name*

Your First Name*

Your Address*

Your City*

State* Please Choose Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Your Zip Code*

Your Telephone*

Your E-mail*

How long have you known this family (in years)?*

Please describe the capacity in which you know them:*

Have you visited the applicant family in their home?* Yes No

If yes, please describe frequency

Please give us your impression of the family. Include your observations of the relationship of the parents to each other, to the child(ren), and vice versa:*

Please describe any unusual conditions including physical or emotional handicaps or disorders that the child(ren) or parents may have:*

Are you aware of any alcoholism, drug abuse, domestic violence, sexual abuse or other problems in the family?* Yes No

If yes, please explain:

Are you aware of any history of arrest or criminal charges involving any family member?* Yes No

If yes, please explain:

Do you believe that the applicant's family would provide a healthy, pleasant homestay experience for a young person from a foreign country?* Yes No

If no, please explain:

Please feel free to make any further comments or observations which you feel would help us to better evaluate the applicants' suitability for hosting an au pair.