Au Pair Germany Application Form

Au Pair Program Application
& Term and Conditions
TO BE COMPLETED BY THE APPLICANT (print in black ink)
PAGE 1 of 2
Program Application: please tick the relevant boxes
Au Pair Programs
Au Pair USA (AP USA)
Au Pair France (AP FRA)
Au Pair Germany (AP GER)
Au Pair Spain (AP ESP)
Eligibility Criteria
Applicants must meet an eligibility criteria as set down by our partner
in each country and Student Placement Australia New Zealand Pty Ltd.
In general these include:
1. Are 18 through 26 years of age.
2. Have at least 200 hours experience in caring for children. (AP USA,
AP FRA & AP GER)
Personal Details
3.
Last Name (as per passport)
First Name (as per passport)
Address
Suburb
State
Phone
Mobile
Email
Postcode
Acceptance in the Program
Consideration of the application will only be made after the receipt of the
fully completed application form and payment of the required deposit. The
applicant will be formally accepted into the program only after:
1.
Student Placement Australia New Zealand Pty Ltd has determined that the
application meets all the requirements for the nominated program.
2.
The sponsoring organization in the nominated program country, has
reviewed and accepted the application.
Are a responsible person who is willing to make a one year
commitment by living as a member of a host family.
4. Have graduated from secondary school in Australia or New
Zealand (i.e. year 12 in Australia and year 13 in New Zealand).
5. Pass a criminal background check
6. Pass a psychometric test (AP USA)
7. Pass a personal interview
8. Are conversant in English
9. Are in good health and a non-smoker.
10. Are energetic and enthusiastic
11. Are a licensed driver. (AP USA, AP FRA & AP GER)
AP USA – willing to provide up to 45 hours of child care assistance each week.
AP FRA – willing to provide up to 35 hours of child care assistance each week.
AP GER, AP ESP – willing to provide 30-40 hours of child care assistance
each week.
Applicants must familiarize themselves with all the relevant eligibility criteria
as outlined on our web site or in our printed materials.
Placement Decisions
All final placement decisions are made by our overseas partners and
communicated to Student Placement Australia New Zealand Pty Ltd.
Included in the Program
Free international return flight for Au Pairs who successfully complete their
12 month program (ex Sydney, Melbourne, Auckland & Wellington). (AP USA
& AP GER ONLY)
Your host family will pick you up from the closest airport or station when you
arrive.
Choice of the departure month that’s best for you. (Note that your departure
time may need to be negotiated between you and your host family to secure a
mutually convenient date).
Comprehensive medical, travel, baggage and personal liability insurance
coverage (includes trip cancellation coverage.)
Placement with a carefully selected Host Family.
Placement opportunities in a variety of areas, in the country of your selected
program.
Your own furnished bedroom in your host family’s home
Weekly pocket money.
Up to two weeks vacation (AP USA & AP FRA) four weeks (AP GER).
The documentation necessary to obtain your Working Holiday or Au Pair visa
for 12 months.
Assistance with obtaining your visa (you must pay the visa & related costs).
Support from our partner in your selected program country including a 24/7
emergency number to call.
The opportunity to be in touch with and socialise with other Au Pairs.
Travelex Visa Cash Passport Card
eKit card.
Placement Offers
The applicant must be prepared to accept the placement offered by
Student Placement Australia New Zealand Pty Ltd and its partners. While
every effort will be made to fulfill placement requests, Student Placement
Australia New Zealand Pty Ltd cannot guarantee that requests will be met.
Dismissal
International and domestic airfares and other transportation (AP FRA,
AP ESP). Note that your international fare will be reimbursed to you when you
Certain circumstances could lead to your host family asking you to leave
the home. If you lose your family due to unacceptable behaviour on your
part, Student Placement Australia New Zealand Pty Ltd. will not find you a
new host family. The following behaviour is not acceptable and will
automatically lead to termination of the program:
•
Drunkenness or use of illegal drugs
•
Any criminal offence
•
Working without a work permit
•
Use of internet or telephone without permission
•
Excessive use of internet or a mobile phone
•
Refusal to help with chores (no more or less than other family
members).
Student Placement Australia New Zealand Pty Ltd reserves the right to
dismiss from the program any applicant who is deemed, by Student
Placement Australia New Zealand Pty Ltd, or our overseas partner to be a
danger to themselves or others or whose conduct is deemed to be
detrimental to the program or their host family. In the event of such
dismissal, Student Placement Australia New Zealand Pty Ltd shall not be
held responsible for any airfare charges or any other expenses incurred by
the applicant, and shall not be required to return any fees paid by the
applicant.
complete a 12 month program successfully, ex Sydney, Melbourne, Auckland &
Wellington (AP USA, AP GER)
Program Fees
Not Included in the Program
Passport fees
Visa fees
All items of a personal nature including expenses for entertainment
www.studentplacement.com.au / www.aupair.org.au
po box 1420, mona vale nsw 1660
www.studentplacement.co.nz / www.aupair.org.nz
suite 2590, po box 83000, wellington 6440
The fees and fee information are correct at the time of publication, but are
subject to change due to currency fluctuations and other unforeseen
circumstances.
experienceiseverything™
abn 81 101 489 052
Au Pair Program Application
& Term and Conditions
TO BE COMPLETED BY THE APPLICANT (print in black ink)
PAGE 2 of 2
Accuracy of Information
Law of the Contract
The applicant agrees that all the information provided in the application is true to the
best of their knowledge and acknowledges that any false or misleading information
may lead to immediate dismissal from the program.
.
This Contract is governed in all respects by the law of the State of New South Wales
and any legal action arising under the Contract shall be litigated only in the appropriate
Court having jurisdiction in that State.
No Warranty
Cancellation Policy
Student Placement Australia New Zealand Pty Ltd makes no representation or
warranty of any kind, expressed or implied, as to the suitability of the program for any
applicant and Student Placement Australia New Zealand Pty Ltd disclaims all such
warranties to ull the fextent permitted by law.
Cancellations will only be accepted in writing and will be effective at the date received
by Student Placement Australia New Zealand Pty Ltd. Refunds will be made according
to the following schedule:
1. If your application does not meet our eligibility criteria you will be refunded in full
2. If you withdraw from the program:
Liability
The applicant shall be responsible for and held liable for all of his or her acts or
omissions along with any loss or damage that results from those acts or omissions
while he or she is on the program. In the event that Student Placement Australia New
Zealand Pty Ltd, suffers any loss or damages as a result of the acts or omissions of
the applicant, then the applicant agrees to indemnify Student Placement Australia New
Zealand Pty Ltd for such loss or damage.
Next of Kin
The applicant must supply Student Placement Australia New Zealand Pty Ltd with
the name and contact details of next of kin, to be contacted in the case of an
emergency.
Personal Health
The applicant is responsible for considering his or her personal health and safety
needs when applying for or accepting a place on the program. If the applicant suffers
from any health or other condition that would create a risk for them while abroad, he or
she should not apply.
•
After acceptance but before placement you will be refunded in full less the
$250 deposit.
•
After a placement but more than 30 days prior to departure you will be
refunded in full less $750.
•
After placement but less than 30 days prior to departure you will be
refunded in full less $1000.
Should you fail to complete your program overseas no refund applies.
Deposit
$250 deposit has been paid or is enclosed
Please indicate your payment method by ticking the relevant box below
1. Cheque or Money Order
Cheque or Money Order enclosed
2. Direct Deposit
Deposit
Please quote invoice number and name. You must pay the exact amount on the
invoice plus any remittance costs incurred.
Applicant Responsibility
AUSTRALIA
The applicant is responsible for reading and carefully considering all materials made
available that relate to safety, health, legal, environmental, political, cultural and
religious customs and conditions in their host community; and must be aware of local
conditions that may present health or safety risks when making daily choices and
decisions. Each applicant must take full responsibility in the event that laws,regulations
or customs are broken, regardless of foreknowledge.
Account Name
Account:
Bank
Address
Program Dates
Participation on the program begins on the first day of placement with the host family
and the program ends on the last day of an applicant’s placement. Should an
applicant choose to renew on the program for a further term, the applicant is
responsible for paying Student Placement Australia New Zealand Pty Ltd the
appropriate extension fee in order to remain on the program.
Travel
All travel before, during and after the program is at the applicant’s own risk. Any
applicant who chooses to operate motorized vehicles is responsible for obtaining the
necessary license, permission and insurance and does so at his or her own risk.
Force Majeure
Student Placement Australia New Zealand Pty Ltd
BSB: 032 196 Account No: 299572
Westpac
Shop 23 Pittwater Place, 10 Park Street, Mona Vale NSW
NEW ZEALAND
Account Name
Account:
Bank
Student Placement Australia New Zealand Pty Ltd
BSB: 03 0252 Account No: 0815935 025
Westpac New Zealand Ltd
Address
79 Queens St, Auckland Central, Auckland
3. Credit Card
Paid Online
Date of Payment D D / M M / Y Y
Payment can be made by Visa or Mastercard by visiting the Student Placement
Australia New Zealand website or by completing the form below:
Card Holder’s Name
Card Number
/
While Student Placement Australia New Zealand Pty Ltd will always endeavour to fulfill
its responsibilities, Student Placement Australia New Zealand Pty Ltd cannot accept
liability or responsibility for any alterations, delay or cancellation caused by threat of
war, fire, sickness, bad weather, acts of government or public authority or other
circumstances amounting to a “force majeure”.
Exp Date
Responsibility
Signature of Applicant
Student Placement Australia New Zealand Pty Ltd, acts only as a customer to the
providers of other services. All tickets, coupons, and orders are issued subject to any
and all terms under which such services are offered or provided. The issuance and
acceptance of such tickets, coupons and orders shall be deemed to be consent to the
additional condition that Student Placement Australia New Zealand Pty Ltd, shall not in
any way be liable for any injury, damage or loss, howsoever caused to the applicant in
the supply of transportation, accommodation or other services.
/
Card Holder Signature
CV
Dated
I have read, understood and accept the above terms and conditions.
Signed by Applicant
Date
If you have any queries please contact one of our program staff on 1300 135 331 (Australia) or 0800 440 079 (New Zealand)
PRIVACY: Student Placement Australia New Zealand Pty Ltd is collecting information about the applicant to assist in determining whether s/he is eligible for the program, to administer the application and to provide information to the overseas partner organisation and host
family concerning the applicant. Student Placement Australia New Zealand Pty Ltd may not be able to process your application, or provide the program to you, if all the requested information is not provided. Information collected and held about you may be used from time to
time for marketing other products and services for which we believe you are eligible. Information you provide may from time to time be disclosed to, and collected from overseas partner organisations, schools, host families and volunteer coordinators. Under the Australian
Privacy Act 2000 and the New Zealand Privacy Act 1993, individuals have rights of access to, and correction of, their personal information. Student Placement Australia New Zealand Pty Ltd will hold all information you give to us at Unit 7 – 9, 1 Mona Vale Road, Mona Vale,
NSW, 2103, Australia. If you want to access your information, or change it, please contact us via info@studentplacement.com.au or info@studentplacement.co.nz.The applicant and their parent/guardian authorise Student Placement Australia New Zealand Pty Ltd to send the
applicant commercial electronic messages for any of the purposes set out in this clause.
www.studentplacement.com.au / www.aupair.org.au
po box 1420, mona vale nsw 1660
www.studentplacement.co.nz / www.aupair.org.nz
suite 2590, po box 83000, wellington 6440
experienceiseverything™
abn 81 101 489 052
AU PAIR APPLICATION /
AU PAIR BEWERBUNG
Germany / Deutschland
Applicant / Bewerber:
_________________________________
Last Name/Nachname
_________________________________
First Name/Vorname
_________________________________
Nationality/Nationalität
_________________________________
Age at Program Start/Alter bei Beginn
Program/Programm:
 12 Monate
 6 Monate
 Other / Sonstiges ____ Months / Monate
Availability / Verfügbarkeit:
Earliest Departure Date / Frühestes Ausreisedatum: ____________________
Latest Departure Date / Spätestes Ausreisedatum: ____________________
INSTRUCTIONS AND APPLICATION CHECKLIST
Congratulations on deciding to apply to the AuPairCare Germany program from Ayusa! Completing this application is
an important first step to becoming an au pair in the heart of Europe. Your application will be shown to our registered
German host families once completed. Take your time to complete this application thoughtfully and clearly, and be
very thorough when you describe your experiences with children.
Please check the boxes for each item once they have been completed:
 Profile Picture: For your profile picture please upload separately a smiling passport-sized photograph
(approx. 2” x 2” or 5cm x 5cm) in the form of a .PDF or .JPEG along with your application.
 Au pair Application: Complete the application online using the writable PDF version enclosed or print it
out and write clearly using black ink.
 Letter to prospective host family: The letter must be one page in length. For detailed instructions please
look inside the application.
 Photograph Collage: A photo collage is highly recommended! Please be creative! For detailed instructions
please refer to the application.
 Medical Record Verification Form: This form is to be completed by an authorized physician and must be
signed and stamped by the doctor. Please also send in a recent (maximum 6 months old) HIV test, which is
required by the insurance company.
 Childcare Recommendations: To be completed by a friend, neighbor or childcare employer/co-worker.
There should be a minimum of TWO childcare references.
 Personal Recommendation: Completed by a friend, neighbor, teacher or employer (non-relatives only).
 Background Check: To be obtained from the local police department in your home country.
Please note: we do not need an advanced background check where fingerprints need to be taken.
 Photocopy of Driver’s License: Please include a photocopy of your national driver’s license. It must be valid
for the length of your stay. You must also arrive with an international driver’s permit (IDP) valid for your entire
stay. The IDP must be applied for AFTER being matched with a host family! It can be obtained at your local AAA
office.
 Photocopy of your passport: Please attach a copy of your passport. It must be valid throughout and 6 months
beyond your stay in Germany.
 Photocopies of German language tests results, transcripts or certificates.
(Please note: homework assignments, group projects and writing exercises cannot be accepted).
 How to submit your application!
 If your application is less than 8MB, please send it to us by e-mail at info@aupaircare.de
 If your application is more than 8MB, please send it to us in separate e-mails or use a service like
largefilesasap.com or yousentit.com, which enables you to upload files! (Preferred Method)
 If you decide to send it to us by post, please make a copy of your application for your records.
Ayusa International e.V.,
C/o Kathrin Schultze, Giesebrechtstr. 10, 10629 Berlin, Germany
2
AUPAIRCARE PROGRAM SUMMARY
A true adventure awaits you - discover the world through the eyes of a German child!
Au pair Profile
Au pair Tasks
You are…
- interested in learning about German culture
and the German language and already know
the basics of the language
- between 18 and 24 years old (18 - 30 years
old if you are a European passport holder)
- experienced in looking after children;
for example, babysitting,internships in
pre-schools, kindergartens or in a
pediatric center; as a camp
counselor or after-school tutor
(minimum of 2 different references)
- Good health and clean criminal record
- preferably have a valid driver’s license
-
Childcare for the host family up to 6 hours per
day for a total of 30 hours per week
An au pair's responsibilities depend on the age of the
children in the host family and generally include:
Keep the children safe at all times.
Feed, bathe, and play with the children.
Housework related to the children (preparing
children’s meals, doing children’s laundry,
making the children’s beds, and so on).
Act as a member of the family by helping with
tasks (setting the table for a meal, helping
with dishes, etc.) around the house.
Act with common courtesy and keep your room
clean, do your own laundry and wash your
dishes.
You might also take the children to
school/kindergarten or accompany them to
various after-school activities.
Benefits and Salary
Ayusa/AuPairCare Germany Support
- Private bedroom and full board
- Monthly stipend of €350
(€260 stipend plus €90 for language
courses and education)
- 2 days of paid vacation per month
(four weeks for a 12-months stay)
- Minimum of 1 ½ free days per week
- Access to transportation (either a local
public transportation pass or a car)
- A comprehensive insurance package for
the entire length of the program, including
health, accident and liability insurance
The Ayusa/AuPairCare office in Berlin will be there
for your support during the entire length of the
program. Additionally, you will have a local
Ayusa/AuPairCare representative living in your area
(max. 2 hours distance) supporting you and your host
family.



Arrival orientation with your local representative
Regular meetings with your local representative
Contact information for the Berlin office and a 24hour emergency phone number
Flight
- If you commit to six months, you will be responsible for paying your own airfare to and from Germany.
- If you commit to a program length of 12 months you will receive a flight ticket to Germany.
- If you successfully complete a 12 months stay with one family, you will receive a free return flight
from your host family.
Program Duration and Confirmation
 I confirm that I have read and understood the program terms and conditions. I agree to a publication of
my profile on the internet and Ayusa/AuPairCare website for the purpose of finding an appropriate host
family.
 I confirm that I have sufficient funds (own or from family members or friends) for a flight ticket back to
my home country (e.g. in case of an emergency at home, early program termination, 6 months applicants).
3
AuPairCare Germany Application
AuPairCare Deutschland Bewerbung
A. PERSONAL DATA/ANGABEN ZUR PERSON
Last Name/Nachname:
First Name/Vorname:
Middle Name / Weitere Vornamen: ______________________
Nickname / Rufname: __________________________________
Birth Date/Geburtsdatum:
Gender/ Geschlecht:  F  M
/
/
(DD/MM/YYYY)
City of Birth/Geburtsstadt: ______________________________ Country of Birth / Geburtsland: _________________________________
Citizenship/Staatsbürgerschaft:
Country of Residence/Aufenthaltsort: ___________________________
Native Language(s)/Muttersprache(n): _________________________________________________________________________________
Street/Straße:
City/Stadt:
State/Staat:
Zip Code/Postleitzahl:
Telephone/Telefon: +___ (____) ________________________
Cell Phone/ Mobiltelefon: +___ (____) ____________________
Country code / Area code / phone no.
Country code / Area code / phone no.
E-Mail (please print):
Skype (please print):
Please send us a copy of your passport! / Bitte schicke uns eine Kopie deines Reisepasses!
• Have you ever lived or traveled outside your country? / Hast du schon jemals in einem anderen Land gelebt oder bist dorthin
gereist?  Yes/Ja  No/Nein If yes, when and where/Wenn ja, wann und wo?
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
• Have you ever lived in or traveled to Germany? / Hast du schon jemals in Deutschland gelebt oder bist dorthin
gereist?  Yes/Ja  No/Nein If yes, when, where and for how long? / Wenn ja, wann, wo und wie lange?
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
• Why do you want to come to Germany? / Warum möchtest du nach Deutschland kommen?
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
4
Religion:
• What is your religious affiliation?
• Religious Participation/Religionsausübung:
 Regularly/Regelmäßig
 Occasionally/Manchmal
 Never/Nie
• How often would you attend religious services while in Germany? / Wie oft möchtest du deine Religion in Deutschland ausüben?
 Regularly/Regelmäßig
 Occasionally/Manchmal
I agree not to impose my religion on the host family and their children.
Ich werde meine Religion nicht meiner Gastfamilie und deren Kinder aufdrängen.
 Yes/Ja
 Never/Nie
 No/ Nein
Smoking:
• Do you smoke? / Rauchst du?
 Yes/Ja
 No/Nein
 Social Smoker /Gelegenheitsraucher
I agree not to smoke in the host family’s home. / Ich rauche nicht im Haus der Gastfamilie.
 Yes, I agree/ Ja, ich stimme zu
 No /Nein
 N/A
I agree not to smoke whenever I am with the children. / Ich rauche nicht im Beisein der Kinder.
 Yes, I agree/ Ja, ich rauche dort nicht
 Nein/ No
 N/A
Please note: most host families prefer non-smoking au pairs. In addition, smoking is also not permitted while working with children. /
Bitte beachte, dass die meisten Gastfamilien nichtrauchende Au pairs bevorzugen und das Rauchen während der Arbeitszeit mit
Kindern verboten ist.
Driver’s License Information:

Do you have a valid driver’s license? / Hast Du einen gültigen Führerschein?
 Yes/ Ja
 No / Nein
If yes, since when? / Wenn ja, seit wann? _____________________________________________________________________
Date of Expiration: __________________

How often do you drive a car?
Wie oft fährst Du Auto?

Are you willing to drive in Germany? / Bist du bereit in Deutschland Auto zu fahren?
 Often (3-7 days/ Oft (3-7 Tage)
 Sometimes (once a week) / Manchmal (einmal pro Woche)
 Seldom (less than twice a month) / Selten (weniger als zweimal pro Monat)
 Yes/ Ja
 No / Nein
Please note: if you want to drive in Germany, you must have both a national driver’s license valid for your entire stay and an
international driver’s permit (IDP) in your possession BEFORE you depart from your home country. Please apply for the IDP only AFTER
you have been matched with a host family and shortly before you depart to Germany!
5
Pets & Allergies:

Are you willing to live in a home with pets? / Bist du bereit mit Haustieren zu leben?
 Yes/ Ja
 No/ Nein
If no, please explain which pets you CANNOT live with. /Wenn nein, erkläre bitte, mit welchen Tieren, du NICHT
leben kannst.
________________________________________________________________________________________________________
• Are you allergic to any animals? / Hast du eine Tierhaarallergie?
• Do you have any other allergies? / Hast du andere Allergien?
• Do you follow a special diet? / Befolgst du eine besondere Diät? (i.e. Vegetarian, etc./z.B. vegetarisch, etc.)
 Yes/ Ja
 No / Nein If yes, please explain: / Wenn ja, welche:
Please note: your host family is not required to prepare special meals for you. If you would like to eat certain food, you must buy and
prepare it yourself. You should also be able to prepare meat products for the children if asked. / Bitte beachte, dass die Gastfamilie
nicht extra für dich kochen muss. Wenn du etwas Bestimmtes essen möchtest, solltest du dies selbst kaufen und zubereiten. Du
solltest außerdem in der Lage sein Fleischprodukte für die Kinder zuzubereiten, wenn gewünscht.
Health:

Do you have chronic/recurring health problems?
Hast du chronische oder wiederkehrende Gesundheitsprobleme?
If yes, which ones? /Wenn ja, welche?
 Yes/ Ja
 No / Nein
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________

Do you take any medication on a regular basis? / Nimmst du regelmäßig Medikamente?
If yes, which ones? /Wenn ja, welche?
 Yes/ Ja
 No / Nein
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
Conduct:

Have you ever been a victim of physical, sexual or emotional abuse?
Warst du jemals Opfer einer körperlichen, sexuellen oder emotionalen Misshandlung?
 Yes/ Ja
 No / Nein
If yes, what happened? /Wenn ja, was ist passiert?
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________

Have you been convicted of or charged with a criminal offence?
Wurdest du jemals verhaftet oder angeklagt?
 Yes/ Ja
 No / Nein
If yes, what for? /Wenn ja, wofür?
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
6
B. FAMILY BACKGROUND/FAMILIENHINTERGRUND
Father/Vater
Full Name/Name:
Occupation/Beruf:
Mother/Mutter
Full Name/Name:
Occupation/Beruf:
Family/Familie
You live with/Du lebst mit:
 Both parents/beiden Eltern
 Mother/Mutter
 Father/Vater
 Alone/allein
Since/Seit: _____________
 Flatmates/in einer Wohngemeinschaft
Since/Seit: _____________
Other Family Members: / Andere FamilLenmitglieder:
Name
Gender/Geschlecht
Age/Alter
Relationship/Verwandtschaft
1.
2.
3.
4.
Living Information/Lebensumstande:

Where do you live? / Wo Lebst du?
 Urban/Städtisch

 Suburban/Vorstädtisch
 Small Town/Kleiner Ort
 Rural Area/Ländlich
Do you have any pets? / Hast du Haustiere?
 Dog/Hund
 Cat/Katze
 Other Pets/Andere Haustiere:
__________________________________________
Tell us about your family! / Erzähle von deiner Familie!
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
7
C. EDUCATIONAL BACKGROUND/SCHULISCHER HINTERGRUND
Academic Education/Bildungsstand
 High School Diploma/Mittlere Reife: _________________ (Date of graduation/Datum des Abschlusses)
 Currently in College/Im Studium: ________________________________ (Major/Type of degree /Fachrichtung)
 Completed College/Abgeschlossenes Studium: _____________________ (Major/Type of degree /Fachrichtung)
 Vocational Training/Lehre: ______________________________________________ (Occupation /Berufsrichtung)
What are you currently doing (school, job, etc.)? / Was machst du momentan (Schule, Arbeit, etc.)?
What are your future career and educational plans? / Was sind deine Berufs- und Bildungspläne für die Zukunft?
Indicate the foreign language(s) you speak and the number of years you have studied each language.
Welche Sprachen sprichst du und seit wie vielen Jahren lernst du diese Sprache?
LANGUAGE/SPRACHE
YEARS/JAHRE
LANGUAGE/SPRACHE
YEARS/JAHRE
Level of German/Deutschkenntnisse (Please send us a German language certificate or transcript if you have one)
 Fluent/Fließend
 Advanced/Forgeschritten
 Intermediate/Befriedigend
 Basic/Grundkenntnisse
 None/Keine
Please note: part of the au pair visa requirements is to attend German classes during your stay. Most Au pairs use Volkshochschule
(community college) which is the most affordable option. / Bitte beachte, dass eine Au pair Visumauflage ist, dass du einen
Deutschkurs während deines Aufenthalts besuchst. Die meisten Au pairs absolvieren diesen in einer Volkshochschule, die das beste
Preis-Leistungs-Verhältnis hat.
8
D. INTERESTS & HOBBIES / INTERESSEN UND HOBBYS
Check all the boxes that describe your current interests and hobbies / Bitte markiere alle Kästchen, die deine momentanen
Interessen und Hobbys beschreiben.
 Drawing/Painting
 Writing
 Reading
 Photography
 Board Games
 Sewing
 Computer
 Gardening
 Cooking
 Baking
 Dining Out
 Socializing
 Travel
 Camping
 Animals
 Church Activity/Community Service
 Drama / Theater
 Concerts
 Choir/Singing  Playing instrument(s)______________________________________
 Handcrafts
 Aerobics
 Basketball
 Baseball
 Football
 Soccer
 Volleyball
 Bowling
 Tennis
 Table Tennis
 Golf
 Bike Riding
 Running
 Skating
 Dancing
 Swimming
 Fitness
 Gymnastics
 Martial Arts
 Hiking
 Watersports
 Horseback Riding
 Sailing
 Skiing
 Snowboarding  Other: __________________________________________________________
E. HOUSEHOLD DUTIES/HAUSHALTSPFLICHTEN
I understand that part of my au pair duties include light household chores. / Ich verstehe, dass Teil meiner Au pair Tätigkeit
das übernehmen leichter Haushaltstätigkeiten beinhaltet.
 Yes/ Ja
 No / Nein
I am able to do the following household activities: / Ich kann folgende Haushaltstätigkeiten:
 Baking/Backen
 Cooking/Kochen
 Washing dishes/Geschirr spülen
 Vaccuming & Mopping/Staubsaugen & aufwischen
 Cleaning my own room & bathroom/Eigenes Zimmer & Badezimmer putzen
 Cleaning the children’s bedroom(s) & bathroom(s)/Kinderzimmer & Kinderbadezimmer aufräumen
 Running small errands/ kleine Besorgungen erledigen
 Changing bedsheets for children /Bettwäsche der Kinder wechsel
 Taking out trash/Müllentsorgung
 Doing Laundry/Wäsche waschen
 Ironing children’s clothing/Kindersachen bügeln
 Dusting/Staubwischen
 Feeding pets/Haustiere füttern
 Walking pets/Haustiere spazieren führen
Please note: looking after your host family‘s children will be your main responsibility during your stay. However, according to the
German au pair visa regulations, you may also be asked by your host family to help them out with light household chores such as the
above.
While you will not have to do all of the above solely by yourself, you will be responsible for keeping your own and the children’s
rooms neat. Also tidying up common rooms used by the whole family (i.e. kitchen, dining room) might be a task of yours. Please be
sure to discuss your exact household duties with your host family during the interview.
Bitte beachte: deine Hauptaufgabe liegt in der Betreuung der Kinder deiner Gastfamilie. Nichtdestotrotz und gemäß den deutschen Au
pair Visumregeln, kann deine Gastfamilie dich auch darum bitten, sie bei leichten Haushaltstätigkeiten zu unterstützen. Während du
nicht für alle oben aufgeführten Tätigkeiten allein verantwortlich bist, bist du dafür zuständig dein eigenes Zimmer als auch die
Kinderzimmer sauber und ordentlich zu halten. Auch das Aufräumen der Zimmer, die von allen Familienmitgliedern genutzt werden
(Küche, Esszimmer), könnte dazu zählen. Besprich daher bitte die konkret von dir erwarteten Haushaltstätigkeiten mit deiner
Gastfamilie während des Interviews.
9
F. EXPERIENCE WITH CHILDREN / ERFAHRUNG MIT KINDERN
Experience with/Erfahrung mit
Comfortable with/Bevorzugte Altersstufen
 Newborn/Neugeboren – 12 months/Monate
 Newborn/Neugeboren – 12 months/Monate
 1 – 2 years/Jahre
 1 – 2 years/Jahre
 3 – 5 years/Jahre
 3 – 5 years/Jahre
 6 –10 years/Jahre
 6 –10 years/Jahre
 Teenagers
 Teenagers
Previous types of childcare / Bisherige Erfahrungen mit Kindern
Special skills / Besondere Talente
 Babysitter for non-related children
 Cooking & Baking / Kochen & Backen
 Babysitter for Siblings & Family / Geschwister & Familie
 First Aid / Erste Hilfe
 Assistant at a Kindergarten & Day Care / Kindertagesstätte
 Life Guard / Rettungsschwimmer
 Camp Counselor / Ferienlager Betreuer
 Newborn classes / Neugeborenenversorgung
 Tutor / Nachhilfe
 Child development class / Babysittingkurse
 Teacher / Lehrer
 Nurse / Krankenpflege
 Nanny & Au pair / Kindermädchen & Au pair
 Swimming / Schwimmen.
 Working with mentally and physically disabled children /
Arbeit mit geistig und körperlich behinderten Kindern
 Bike Riding / Radfahren.
What kind / Welcher Art: ____________________________
I have experience with the following childcare-related activities:
 Bottle Feeding/Flasche geben
 Preparing Baby Formula/Flasche zubereiten
 Bathing/Baden
 Playing/Spielen
 Changing diapers/Windeln wechseln
 Put to bed/ins Bett bringen
 Dealing with tantrums/beruhigen
 Spoon feeding/füttern
 Potty training/Sauberwerden
 Baby swimming/Babyschwimmen
 Practice speaking/Sprechen üben
 Tutoring/Nachhilfe
 Burping a baby/”Bäuerchen” machen
 Supervising/Betreuung
 Caring for sick children/kranke Kinder betreuen
 Caring for colicking baby/krankes Baby betreuen
 Accompanying during activities/zu Aktivitäten begleiten
 Other/Anderes: ____________________________________
What do you enjoy about taking care of infants and toddlers? / Was gefällt dir an der Arbeit mit Babys und Kleinkindern?
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
What do you enjoy about taking care of children over 2 years? / Was gefällt dir an der Arbeit mit Kindern über 2 Jahren?
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
10
G. HISTORY OF CHILDCARE WORK / ARBEITSERFAHRUNG MIT KINDERN
Type of Childcare: _______________________________  Seasonal (i.e. winter & summer)  Temporary (irregularly)  Yearlong
Child First Name:
Gender:
Start Age:
End Age:
Start Date:
End Date:
_____________
_______
_______
_______
____/____ /_____
____/____ /_____
_____________
_______
_______
_______
_____________
_______
_______
_______
_____________
_______
_______
_______
Reference Name:
_________________________
Average number of hours worked per month: ______________________
Type of Childcare: _______________________________  Seasonal (i.e. winter & summer)  Temporary (irregularly)  Yearlong
Child First Name:
Gender:
Start Age:
End Age:
_____________
_______
_______
_______
_____________
_______
_______
_______
_____________
_______
_______
_______
_____________
_______
_______
_______
Start Date:
____/____ /_____
End Date:
____/____ /_____
Reference Name:
_________________________
Average number of hours worked per month: ______________________
Type of Childcare: _______________________________  Seasonal (i.e. winter & summer)  Temporary (irregularly)  Yearlong
Child First Name:
Gender:
Start Age:
End Age:
_____________
_______
_______
_______
_____________
_______
_______
_______
_____________
_______
_______
_______
_____________
_______
_______
_______
Start Date:
____/____ /_____
End Date:
____/____ /_____
Reference Name:
_________________________
Average number of hours worked per month: ______________________
Type of Childcare: _______________________________  Seasonal (i.e. winter & summer)  Temporary (irregularly)  Yearlong
Child First Name:
Gender:
Start Age:
End Age:
_____________
_______
_______
_______
_____________
_______
_______
_______
_____________
_______
_______
_______
_____________
_______
_______
_______
Start Date:
____/____ /_____
End Date:
____/____ /_____
Reference Name:
_________________________
Average number of hours worked per month: ______________________
11
H. SHORT ESSAYS/ KURZE FRAGEN
The biggest concerns for German host families are au pairs who: 1) behave like one of the children in the family, 2) constantly skype
with friends & family during on-duty times, 3) are unable to see what needs to be done on their own, 4) only work with instructions,
5) fail to adjust to the daily lifestyle of the family, and 6) do not show any motivation or enthusiasm to be in Germany.
Die größte Sorge einer Gastfamilie ist ein Au pair, das: sich wie ein weiteres Kind der Familie verhält/ ständig während der Arbeitszeit
skypt/ nur nach Anweisung arbeitet/sich dem Alltag nicht anpasst/ keinerlei Motivation und Enthusiasmus zeigt.
• Why do you want to become an Au pair?/ Warum möchtest Au pair werden?
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
• What are your strengths with children (special skills/talents)? / Was sind deine Stärken mit Kindern (Fähigkeiten/Talente)?
What activities would you like to do with your host children? / Welche Aktivitäten würdest du mit den Gastkindern
unternehmen?
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
•
What qualities do you need in order to adapt to the host family´s way of life? / Welche Qualitäten brauchst du, um dich an den
Lebensstil deiner Gastfamilie anzupassen?
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
• Why should a family pick you as their au pair? / Warum sollte eine Familie dich als ihr Au pair aussuchen?
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
• What do you think will be the most challenging part of being an au pair? / Was denkst du, wird der schwierigste Teil
deines Au pair Jahres sein?
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
• If you experience homesickness in Germany, what method will you use to overcome this? / Wenn du in Deutschland
Heimweh bekommst, wie wirst du es überwinden?
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
12
I. AU PAIR LETTER / AU PAIR BRIEF
Please prepare a well-written typed letter for your future host family in the space provided below. Explain why you want
to live and work as an au pair in Germany. Write about your interests, expectations, family and friends; but most
importantly, about your work experiences with children. Please emphasize why you enjoy being around children.
Bitte schreibe hier einen getippten Brief an deine zukünftige Gastfamilie. Schreibe, warum du in Deutschland als Au pair
leben willst. Schreibe über deine Interessen, Erwartungen, Familie und Freunde und besonders über deine Erfahrung mit
Kindern. Erzähle, was dich an Kindern begeistert.
13
J. PHOTO COLLAGE / FOTO COLLAGE
This collage is for your host family to gain a better understanding of your childcare experience & lifestyle.
Remember, first impressions count!
Follow these tips when creating your collage:




Include predominantly photos of yourself with children you have worked with (minimum of four photos!)
Include photos of family and friends
Write captions underneath each photo
Create a 2 page photo collage
Create your photo collage by using, i.e Microsoft Word, Clip Art, iPhoto, iWork etc. Please save the photo collage as a .doc or .pdf.
However, if you do decide to use a separate piece of paper to create your photo collage, please make sure to scan it in color & high
resolution.
Dieses Fotoalbum ist für deine Gastfamilie, damit sie sich ein besseres Bild von deinen Kinderbetreuungserfahrungen &
Lebensstil machen können. Es sollte daher vor allem Fotos enthalten von dir und Kindern, mit denen du gearbeitet hast,
aber natürlich auch von deiner Familie und Freunden. Das Album sollte 2 Seiten umfassen und jedes Foto sollte eine
kleine Bildunterschrift haben.
14
M. CHARACTER REFERENCE /CHARAKTERREFERENZ
Applicant’s Name: ___________________________________________________________________
The applicant presenting you with this form would like to be accepted by Ayusa for the AuPairCare Germany program. If accepted,
she/he will spend time in a German 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 will be
contacted by the local office to confirm this reference.
1. How long have you known this applicant? _______ 2. How do you know this applicant? _____________________________________
(example: employer, neighbor, friend, etc.)
3. How would you describe this person’s character?
□
□
□
□
□
Active
Adaptable
Creative
Efficient
Good communication
□ Family-oriented
□ Flexible
□ Humorous
□ Independent
□ Punctual
□
□
□
□
□
Open-minded
□
Outgoing
□
Polite
□
Positive
□
Other: _______________
Sociable
Sporty
Warm-hearted
Reliable
4. Please describe why you believe the applicant is suitable for the AuPairCare Germany program. List any relevant skills and
abilities the applicant has demonstrated:
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
5. Additional comments on the applicant’s character:
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
6. Reference Information:
Name: _____________________________________________________________________________
Address: ___________________________________________________________________________
Email address: ______________________________________________________________________
Signature: _________________________________________________________ Date:___/___/_____
May a prospective host family contact you ? ____ Yes ____ No
(For Office Use Only) Verified By: ___________________________________ Date: ___/___/____
L. CHILDCARE REFERENCE /KINDERBETREUUNGSREFERENZ - 1
Applicant’s Name / Name des Bewerbers: ___________________________________________________________________
The applicant presenting you with this form would like to be accepted by Ayusa for the AuPairCare Germany program. If accepted,
she/he will spend time in a German 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 will be
contacted by the local office to confirm this reference.
1. How long have you known this applicant? _______ 2. How do you know this applicant? _____________________________________
(example: employer, neighbor, friend, etc.)
3. How do you know that the applicant can take care of children?
□ The applicant has taken care of my children
□ I have supervised the applicant with children
□ We have worked together with children
□ Other: _______________________________
4. When did the applicant care for the child(ren)?
Start Date:___/___/____ Stop Date:___/___/____
5. How frequently did the applicant take care of the child(ren)? ________________________________________________________
Please list the number of ages of the child(ren) for whom the applicant cared:
_________________________________________________________________________________________________________________
6. Please state the applicant’s duties and activities during this period:
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
7. Please describe skills and abilities this applicant showed while caring for the children:
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
8. Reference Information:
Name: _____________________________________________________________________________
Address: ___________________________________________________________________________
Email address: _____________________________________________________________________
Signature: _________________________________________________________ Date:___/___/_____
May a prospective host family contact you ? ____ Yes ____ No
(For Office Use Only) Verified By: ___________________________________ Date: ___/___/_____
L. CHILDCARE REFERENCE /KINDERBETREUUNGSREFERENZ - 2
Applicant’s Name / Name des Bewerbers: ___________________________________________________________________
The applicant presenting you with this form would like to be accepted by Ayusa for the AuPairCare Germany program. If accepted,
she/he will spend time in a German 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 will be
contacted by the local office to confirm this reference.
1. How long have you known this applicant? _______ 2. How do you know this applicant? _____________________________________
(example: employer, neighbor, friend, etc.)
3. How do you know that the applicant can take care of children?
□ The applicant has taken care of my children
□ I have supervised the applicant with children
□ We have worked together with children
□ Other: _______________________________
4. When did the applicant care for the child(ren)?
Start Date:___/___/____ Stop Date:___/___/____
5. How frequently did the applicant take care of the child(ren)? ________________________________________________________
Please list the number of ages of the child(ren) for whom the applicant cared:
_________________________________________________________________________________________________________________
6. Please state the applicant’s duties and activities during this period:
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
7. Please describe skills and abilities this applicant showed while caring for the children:
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
8. Reference Information:
Name: _____________________________________________________________________________
Address: ___________________________________________________________________________
Email address: _____________________________________________________________________
Signature: _________________________________________________________ Date:___/___/_____
May a prospective host family contact you ? ____ Yes ____ No
(For Office Use Only) Verified By: ___________________________________ Date: ___/___/_____
K. PHYSICIAN'S STATEMENT OF HEALTH-1/ÄRZTLICHES GUTACHTEN-1
—To be completed by physician/Vom Arzt auszufüllen
Au pair Name/Name des Au pairs
Birth date/Geburtsdatum
Day
/
/______
Month
Year
1. Has the applicant ever had any of the following illnesses? If yes, give dates of illness and detailed information regarding
any impairment./Hatte der Bewerber eine der folgenden Krankheiten? Falls ja, bitte schreiben Sie wann und geben Sie
gegebenenfalls Informationen zu Beeinträchtigungen.
Chicken Pox/Windpocken
Measles/Masern
Mumps
Rubella/Röteln
Malaria
Scarlet Fever/Scharlach
Rheumatic Fever/Gelenkrheumatismus
Vertigo, Dizziness/Schwindelanfälle
Dyslexia / Legasthenie
Learning Defect/Lernschwäche
Meningitis
Poliomyelitis/spinale Kinderlähmung
Cancer/Krebs
Typhoid/Typhos
Appendicitis/Blinddarmentzündung
Hernia/Leistenbruch
Diabetes Mellitus/Diabetiker
Ulcers/Magengeschwüre
Allergies/Allergien
Asthma
Pneumonia/Lungenentzündung
Tuberculosis / Tuberkulose
Persistent cough/chronischer Husten
Migraines, Migräne
Goiter (Struma)/Kropf
Epilepsy / Epilepsie
Enuresis/Bettnässen
Sleepwalking/Schlafwandeln
Mental disorder/Geistesstörung
Hyper/Hypothyroidism/Schilddrüsenüber/unterfunktion
Cold Sores / Lippenherpes
Hepatitis/Leberentzündung
If yes, what type / Wenn ja, welcher Typ
YES/JA
NO/NEIN
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






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A
B
C
• Does the applicant have any allergies?/Hat der Bewerber Allergien?
If yes, please describe./Falls ja, bitte beschreiben sie welche.
2.
 Yes/Ja
DATE/DATUM
 No/Nein.
Has the applicant experienced disease, impairment or abnormality of any of the following?/Hat(te) der Bewerber
Krankheiten, Beeinträchtigungen oder Abnormalitäten in einem der folgenden Bereiche ?
Eyes or Sight/Augen oder Sehkraft
Ears or Hearing/ Ohren oder Hören
Nose or Smell/Nase oder Riechen
Throat, Tonsils/Rachen, Mandeln
Skin (acne etc.)/ Haut (Akne, etc.)
Lungs, respiratory system/Lunge, Atemwege
Sexually transmitted diseases/Geschlechtskrankheiten
Muscle system/Muskelsystem
Stomach or digestive system/
Magen oder Verdauungsorgane

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PHYSICIAN'S STATEMENT OF HEALTH-2/ÄRZTLICHES GUTACHTEN-2
—To be completed by physician/Vom Arzt auszufüllen
Heart or vascular system/ Herz oder Kreislauf
Genito-Urinary System/Geschlechts- u. Harnwegstrakt
Other Abdominal Organs /weitere abdom. Organe
Bones, Joints/Knochen, Gelenke
Blood, Endocrine Sys./ Blut, endokrine Systeme
Brain, Nervous System/Gehirn, Nervensystem
Menstrual problems/Menstruationsbeschwerden
YES/JA


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



NO/NEIN





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
DATE/DATUM
For all checked items, please give details, nature and severity of disorder, frequency and treatment./
Für alle angekreuzten Erkrankungen fügen Sie bitte eine Erklärung über Symptome und Behandlung bei.
• Is the applicant currently using any prescription drugs or injections (other than birth control)?/Verwendet der Bewerber
zurzeit verschriebene Medikamente oder Injektionen (außer Verhütungsmittel)?  Yes/Ja  No/Nein.
If yes, give details and list specific drugs being used./Falls ja, bitte nennen und erklären Sie welche:
• If the applicant is allergic to any medications, please list the names and what substitutes should be used. / Wenn der
Bewerber allergisch ist gegen Medikamente, geben Sie bitte die Namen an und die Ersatzmedikamente dafür.
• Has the applicant ever been hospitalized? / War der Bewerber jemals im Krankenhaus?
 Yes / Ja  No / Nein
If yes, please explain further (reason, dates, etc.) / Wenn ja, bitte erklären (Grund, Daten, etc.)
3.
Has the applicant been immunized against the following?/ Hat der Bewerber die folgenden Impfungen?
DATE/DATUM
 Polio/Kinderlähmung
 Measles/Masern
 Mumps
4.
_______
_______
_______
DATE/DATUM
 Diphteria/Diphterie_________
 TB / Tuberkulose _________
 Whooping cough/ _________
Keuchhusten
DATE/DATUM
 Tetanus
 Röteln/Rubella
 Other/Andere
________
________
________
Does the applicant present or has presented any evidence of nervous, emotional or mental problems? / Hat der
Bewerber Anzeichen von nervösen, emotionalen oder mentalen Problemen/Störungen (gezeigt)?
 Yes/Ja
 No/Nein
Has the applicant ever received psychological counselling or treatment?/War der Bewerber jemals in psychologischer
Behandlung?
 Yes/Ja
 No/Nein
Has the applicant ever received treatment or counselling for emotional depression or distress? / War der Bewerber
jemals in Behandlung oder hat therapeutische Beratung erhalten wegen emotionaler Depressionen oder Probleme?
 Yes/Ja
 No/Nein
Has the applicant ever received treatment regarding any eating disorders? / War der Bewerber jemals in Behandlung
wegen Essstörungen?
 Yes/Ja
 No/Nein
Has the applicant ever used any stimulant, anti-depressant, sedative drugs (valium etc.)? / Hat der Bewerber jemals
Aufputschmittel, Antidepressiva oder Sedativa eingenommen?
 Yes/Ja
 No/Nein
Has the applicant ever used any narcotic, barbituarates or other addictive drugs? / Hat der Bewerber jemals Drogen,
Barbiturate oder andere abhängig machende Medikamente eingenommen?
 Yes/Ja
 No/Nein
Has the applicant been on a restricted diet or restricted living routine? / Musste der Bewerber jemals eine besondere
Diät oder besondere Tagesabläufe einhalten?
 Yes/Ja
 No/Nein
If any of the answers has been „yes“, please give details./ Bitte fügen Sie Erklärungen bei, wenn die Antwort „ja“ ist.
_______________________________________________________________________________________________________
________________________________________________________________________________________________________
PHYSICIAN'S STATEMENT OF HEALTH-3/ÄRZTLICHES GUTACHTEN-3
— Continued / Fortführung
• Give your opinion of the general state of the applicants health./Bitte beurteilen Sie den allgemeinen
Gesundheitszustand des Bewerbers.
 Excellent/Ausgezeichnet
 Good/Gut
 Fair/Befriedigend
 Poor/Schlecht
If applicants health is only fair or poor, please explain./Falls die Gesundheit des Bewerbers nur befriedigend oder
schlecht sein sollte, erklären Sie das bitte.
• Does the applicant have any health limitations (physical or emotional) that would limit her / his participation in a
program where she / he will be providing childcare? / Hat der Bewerber gesundheitliche Beschränkungen (körperlich
oder emotional), die seine/ihre Teilnahme an einem Programm einschränkt, bei dem sie / er Kinder betreut?
 Yes/Ja
 No/Nein. If, yes, please explain/Falls ja, bitte erklären Sie das.
• Provide information for the following./Bitte geben Sie die folgenden Informationen.
Height/Größe:
Weight/Gewicht:
meters/Meter
centimeters/Zentimeter
kilograms/Kilogramm
I, the undersigned physician, have given a thorough physical examination and reviewed the medical history of the
candidate and certify that all important medical information has been included and that the above information is
accurate./ Ich, der unterzeichnende Arzt, habe eine gründliche ärztliche Untersuchung durchgeführt und die medizinische
Vergangenheit des Kandidaten geprüft. Ich bestätige, dass alle wichtigen medizinischen Informationen enthalten sind und
die obrigen Informationen akurat sind.
Physician's Name (print)/
Physician's Signature/Unterschrift des Arztes
Name des Arztes(in Druckbuchstaben)
Date/Datum