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Agentura Ariane
Poláčkova 1613
Strážnice 69662
Tel.: 603 53 43 43
Email: [email protected]
web: www.agentura-ariane.cz
Personal Information
Name and Surname:
………………………………………………………………………………………………………………………
Age: …………………
Date of birth: …………………………………………….
Citizenship: ………………………………
Religion: …………………………………………….
Mother´s occupation: ……………………
Father´s occupation: …………………………….
Age of brothers/sisters: ………………………………………………..………………………………….
What type of location do you currently live*?
☐ City
☐Town ☐Village
☐Countryside
Are you*:
☐ Single
☐Married
☐Divorced
Qualification*:
☐ A-level (maturita)
☐Stateexam (státnice)
☐Other: ……………………….............
Describe your school education: …………………………………………………………………….
Present/Previousjob/school:……………………………………….………………………………..
Level of English*:
☐good
☐ very good
☐ fair
English studied for: ………………………..
☐poor
☐months
☐years
Other languages: ……………………………………………
Driving skills:
Drivers licence*:
☐Yes
☐ No
Are you happy to drive abroad"? ......☐Yes☐ No
If you are a driver, when did you receive your driver's license?
Month:………. Year: ……….
Have you ever had a car accident*? ……………………..
☐Yes
☐ No
If yes, please write details: ………………………………………………………………………………….
How often do you drive*:
☐city
Type of roads*:
☐daily
☐weekly
☐monthly
☐rarely
☐town ☐rural
Hobbies/Interests*:
☐ Sports
☐ Arts
☐ Animals/Pets
☐ Swimming
☐ Travelling
☐ Music
☐ Cinema
☐ History
☐ Photography
☐ Reading
☐ Cooking
☐ Other: …………………………………………………………………………………
Are you in good health?........................
☐Yes
☐ No
Do you have allergies?
☐Yes
☐ No
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Agentura Ariane
Tel.: 603 53 43 43
Email: [email protected]
web: www.agentura-ariane.cz
Poláčkova 1613
Strážnice 69662
☐Yes
Can your allergies affect your work?
☐ No
If allergic, please give details: ………………………………………………………………………………..
Do you smoke*?
☐Yes
☐No
☐Social smoker (occassional smoking) ☐Not in the house
Which month can you start? …………………. Earliest starting day? …………………………….
Length of your stay*?
☐ 3 months
☐ 6 months
☐ 10 months ☐ 12 months+ ☐Other: ………. Months
(the longer you can stay the better)
Can you stay longer if satisfied in your host family*?
☐Yes
☐ No
Position*:
Preferences*: ☐Au Pair
☐Au Pair Plus
Country:
☐England
☐ Ireland
Location:
☐cap i t al
☐ci t y
☐Mini Mother's Help
☐Mother's Help
☐town ☐village/farm ☐don't mind
Do you wish to attend language classes*? ………………………………☐Yes☐ No ☐Maybe
Are you willing and able to assist with the following duties*?
☐Light housework
☐Simple cooking
☐Babysitting
☐Caring for pets
CHILDCARE INFORMATION
Are you willing to work with following age group*?
☐ 0-3
☐ 3-10
☐ 4-10
☐ 10+
Which age group do you have experience with*?
☐ 0-2
☐ 2-4
☐ 4-10
☐ 10+
☐any
Childcare experience 1* :
☐family /brothers, sisters/
☐children of relatives /cousins/
☐children in neighborhood
☐children of your friends
Names / Ages / Sex: ……………………………………………………………………………………..
Activities / Duties**: …………………………………………………………………………………………
…………………………………………………………………………………………………………………..
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Agentura Ariane
Poláčkova 1613
Strážnice 69662
Tel.: 603 53 43 43
Email: [email protected]
web: www.agentura-ariane.cz
For how long / how often: ………………………………………………………………...…………….
Childcare experience 2* :
☐family /brothers, sisters/
☐children of relatives /cousins/
☐children in neighborhood
☐children of your friends
Names / Ages / Sex: ……………………………………………………………………………………..
Activities / Duties**: …………………………………………………………………………………………
…………………………………………………………………………………………………………………..
For how long / how often: ………………………………………………………………...…………….
Childcare experience 3* :
☐family /brothers, sisters/
☐children of relatives /cousins/
☐children in neighborhood
☐children of your friends
Names / Ages / Sex: ……………………………………………………………………………………..
Activities / Duties**: …………………………………………………………………………………………
…………………………………………………………………………………………………………………..
For how long / how often: ………………………………………………………………...…………….
Childcare experience 4, 5* :
☐summer camp
☐trainer's assistant
☐trainer
☐children's homes
☐nursery
☐kindergarten
☐private teaching
☐qualified nurse
☐au pair
☐school
☐other: ……………………………………………………
Names / Ages / Sex: ……………………………………………………………………………………..
Activities / Duties**: …………………………………………………………………………………………
…………………………………………………………………………………………………………………..
For how long / how often: ………………………………………………………………...…………….
Names / Ages / Sex: ……………………………………………………………………………………..
Activities / Duties**: …………………………………………………………………………………………
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Agentura Ariane
Poláčkova 1613
Strážnice 69662
Tel.: 603 53 43 43
Email: [email protected]
web: www.agentura-ariane.cz
…………………………………………………………………………………………………………………..
For how long / how often: ………………………………………………………………...…………….
Have you ever been convicted of any criminal offence*?
☐Yes
☐ No
If yes, please give full details: ….………………………………………………………………………..
I have read and understood this Application form. All the information given is true and complete.
Přečetl/a a porozuměl/a jsem tomuto formuláři. Všechny uvedené informace jsou pravdivé a
kompletní. Jsem si vědom/á, že zodpovídám za poskytnutí nepravdivých anebone kompletních
informací a následky z toho plynoucí.
Signed: …………………………………………….. Date: …………………….…………………………
*vyznačte prosím vhodnou odpověď zaškrtnutím příslušného čtverečku anebo více čtverečků
**Activities/Duties - examples: playing, drawing, painting, arts and crafts, ball games, park, nature,
cycling, assisting with bathing, feeding children, preparing meals / supper/ dinner, evening
babysitting, school schedule, help with homeworks, solecharge...etc.
Note for foreign agents: It is strictly forbidden to remove any part of this form or change the
information given.
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Agentura Ariane
Poláčkova 1613
Strážnice 69662
Tel.: 603 53 43 43
Email: [email protected]
web: www.agentura-ariane.cz
Children recommendation/Doporučení o péči s dětmi
Please answer the following as honestly and completely as possible. The answers will be used
to assist us and our British partner agencies in placing the applicant with a host family for the
position of an au pair.
Vyplňte prosím následující formulář co nejúplněji a nejpravdivědi. Vaše odpovědi nám a našim
britským partnerským agenturám pomůžou v umístění žadatele v hostitelské rodině na pozici
au pair.
Applicant's name/Jméno uchazeče:
For how long have you known the applicant?/Jak dlouho znáte uchazeče?
When did the applicant take care of the children?/Kdy se uchazeč staral o děti?
From: …………………………….. To ………………………………………. on going
od: ……………………………….. do ……………………………………….... stále přetrvává
Please write down the name, sex and age of the children looked after/Prosím uveďte jména,
pohlaví a věk dětí, o které se uchazeč staral
…………………………………………………………………………………………………………….
…………………………………………………………………………………………………………….
Please explain the applicant's duties with the children/Uveďte povinnosti žadatele, activity
vykonávané s dětmi
…………………………………………………………………………………………………………….
…………………………………………………………………………………………………………….
Please describe applicant's personality, why would they be a good an pair/Prosím charakterizujte
uchazeče, proč si myslíte, že bude vhodný na práci au pair
…………………………………………………………………………………………………………….
…………………………………………………………………………………………………………….
Please add any additional information you would like to give us about the applicant/Uveďte
jakékoli další informace o uchazeči
…………………………………………………………………………………………………………….
…………………………………………………………………………………………………………….
V případě potřeby můžete využít druhou stranu pro další informace o uchazeči.
Name and surname/Jméno a příjmení: …………………………………………………………..
Address/Adresa: ………………………………………………………………………………………
Phone/Telefon: …………………………………………………………………………………………
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Agentura Ariane
Poláčkova 1613
Strážnice 69662
Tel.: 603 53 43 43
Email: [email protected]
web: www.agentura-ariane.cz
(pro potřeby ověření českou agenturou)
Signature/Podpis: …………………….….
Date Datum: ……………………………...
Comments (for agency use only):
Checked by: …………………….….
Date: …………………….….
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Agentura Ariane
Poláčkova 1613
Strážnice 69662
Tel.: 603 53 43 43
Email: [email protected]
web: www.agentura-ariane.cz
Personal recommendation/Charakterové doporučení
Please answer the following as honestly and completely as possible. The answers will be used
to assist us and our British partner agencies in placing the applicant with a host family for the
position of an au pair.
Vyplňte prosím následující formulář co nejúplněji a nejpravdivěji. Vaše odpovědi nám a našim
britským partnerským agenturám pomůžou v umístění žadatele v hostitelské rodině na pozici
au pair.
Applicant's name/Jméno uchazeče
………………………………………………………………………………….
For how long have you known the applicant?/Jak dlouho znáte uchazeče?
………………………………………………………………………………….
What is your relationship to the applicant?/V jakém jste vztahu k uchazeči?
………………………………………………………………………………….
Please describe the applicant's character. Please check the 10 most applicable/Popište
prosím charakterové vlastnosti žadatele. Zaškrtněte 10 nejvýstižnějších vlastností.
Active/aktivní
Friendly/Přátelská/ý
Positive/Pozitivní
Adaptable/Přizpůsobivá/ý
Hardworking/Usilovná/ý
Reliable/Spolehlivá/ý
Caring/Starostlivá/ý
Helpful/Nápomocná/ý
Responsible/Zodpověsná/ý
Creative/Kreativní
Humorous/Se smyslem pro humor
Sociable/Společenská/ý
Energetic/Energetická/ý
Independent/Nezávislá/ý
Takesinitiative/Iniciativní
Family-oriented/Rodinnězaložená/ý
Mature/Vyspělá/ý
Polite/Zdvořilá/ý
Wann-hearted/Dobrosrdečná/ý
Flexibile/Flexibilní
Other/Jiné ………………………………………………………………………………….
Please describe applicant's personality, why would they be a good an pair/Prosím charakterizujte
uchazeče, proč si myslíte, že bude vhodný na práci au pair
…………………………………………………………………………………………………………….
…………………………………………………………………………………………………………….
Please describe applicant's abilities, skills:/Prosím popište zručnosti a schopnosti uchazeče:
…………………………………………………………………………………………………………….
…………………………………………………………………………………………………………….
V případě potřeby můžete využít druhou stranu pro další informace o uchazeči.
Name and surname/Jméno a příjmení: …………………………………………………………..
Address/Adresa: ………………………………………………………………………………………
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Agentura Ariane
Poláčkova 1613
Strážnice 69662
Tel.: 603 53 43 43
Email: [email protected]
web: www.agentura-ariane.cz
Phone/Telefon: …………………………………………………………………………………………
(pro potřeby ověření českou agenturou)
Signature/Podpis: …………………….….
Date Datum: ……………………………...
Comments (for agency use only):
Checked by: …………………….….
Date: …………………….….
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Agentura Ariane
Poláčkova 1613
Strážnice 69662
Tel.: 603 53 43 43
Email: [email protected]
web: www.agentura-ariane.cz
DEAR FUTURE FAMILY;
I am looking forward to come into your family and want to take this
opportunity to tell von about me and where I live. My name is Gabriela, ever
one calls me simply Gaby. My family consists of my mother Dana (42), my twin
sisters Katarina and Pavia (10) and my stepbrother (30). I grew up in Popovica
(a small village).After I finished my primary school I moved to bigger town. There
I went to school for tourism but after some time I move back to my family.
After I graduates high school a graduated all with A) moved into my own
apartment in Olomouc.
From September 2004 I have been working for TV company First I
started like a business secretary, after two and half months I have been
promoted and since then I have been working like TV programming and
acquisition executive. I didn't continued with my college because I wanted to
have one year free for my trip to Great Britain, to see this land and to learn
language and then go on some college but I got this good job. I tried to
work and go to the college at the same time, but that´s not impossible with
this kind of job. I work until 6 — 6.30 pin. So I decided to earn enough money
to pay this program and spend one year in Great Britain working like
babysitter. It is my dream to knew Great Britain.
My mother is housewife. She is my mother but she is also one of my best
friends. I likes spend my time with her. She is very modern woman. She is 45
monites from me and I spend my weekends with her and my sisters. Almost
every Saturday we go to shopping and to take a brunch. My father is Vladimir;
after he finished high school he was studying mechanical engineering. After
he had received degree he had worked like director in one company. My
parents are divorced. But
Tin still a happy child and I 'in not sort), because they are divorced. Every
week I go to visit my father
My experience with children started with my sisters when I was only 10,
because my parents had to work I took care about my sisters. Thru this period I
learned everything about children. I decide to take care about boys because I
needed money for my trips. I like to travel. But at the same time I started to
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Agentura Ariane
Poláčkova 1613
Strážnice 69662
Tel.: 603 53 43 43
Email: [email protected]
web: www.agentura-ariane.cz
love these children like they are my blood. Steffany is one really beautifulchild.
I called her little princess. What I did with children — giving them a bath,
playing with them, changing diapers, changi ng a clothes, taking them to
school, circus, theatre, playground, parks to play with another children, playing
with cars, puzzle, legos, watching cartoons, feed them, taking them to doctor;
go to shopping, in warmer months taking them outside and to swimmi ng pools,
prepare dinner or breakfast, read a book ....
My passion is travelling, I have been until now in Italy; Slovenia,
Hungary); Germany (for a months by my aunt), Great Britain, Poland, Austria,
Greece, Switzerland, . And my favourite destination was Thailand. This is
something amazing. For me it is the most beautifulplace on earth. I had so big
desire to visit it. I had some money from babysitting and the rest my parents
gave me because I graduated all with A. I was there alone for 10 days and I
were everywhere. It was my best experience in life.
What I expect from my host family? I 'in expecting support and equally
attitude with children, with mine communication with people there and with
their culture, English traditional and I would like to attend their college. I look
forward to come into your home and to making my time with you a
rewarding, educational and enjoyable experience.
Sincerely Gaby :7)
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Agentura Ariane
Poláčkova 1613
Strážnice 69662
Tel.: 603 53 43 43
Email: [email protected]
web: www.agentura-ariane.cz
Medical Certificate
Name/Jméno: ………………………………………………………………………………………………
Surname/Příjmení: ………………………………………………………………………………………….
Date of Birth/Datum narození: ……………………………………………………………………………
Date of examination/Datum vyšetření: …………………………………………………………………
Notes/Poznámky: …………………………………………………………………………………………..
Conclusion: I certify, that according to my examination of today the above named does not
show any evidence of acute or any other chronic diseases.
I judge his/her state of mental and psychical health as very good and I believe he/she is fully
able to work as an au pair with a foreign family.
Signature of Physician:
Podpis a razítko lékaře:
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