Agentura Ariane Poláčkova 1613 Strážnice 69662

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


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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For how long / how often: ………………………………………………………………...……………. Childcare experience 2* : ☐family /brothers, sisters/




Names / Ages / Sex: …………………………………………………………………………………….. Activities / Duties**: ………………………………………………………………………………………… ………………………………………………………………………………………………………………….. For how long / how often: ………………………………………………………………...……………. Childcare experience 3* : ☐family /brothers, sisters/




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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………………………………………………………………………………………………………………….. 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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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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(pro potřeby ověření českou agenturou) Signature/Podpis: …………………….….

Date Datum: ……………………………...

Comments (for agency use only):

Checked by: …………………….….

Date: …………………….….

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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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Phone/Telefon: ………………………………………………………………………………………… (pro potřeby ověření českou agenturou) Signature/Podpis: …………………….….

Date Datum: ……………………………...

Comments (for agency use only):

Checked by: …………………….….

Date: …………………….….

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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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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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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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Agentura Ariane Poláčkova 1613 Strážnice 69662

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