Application form for Mothers Help

If you would like to download a printable PDF version of the application form please click here

Please complete the form below

Surname:

First name(s):

Date of Birth:
Male:
Female:

Nationality:

Country of Birth:

Occupation:

What is you current salary?

(per year) or
(per week)

Religion:

Practising

Address:

Postcode:

Phone (Home):

Phone (Mobile):

E-mail:

Passport Number:

Maximum Period Available

Start Date:

Length of Stay:

6 months;

2 years;

12 months;

Others (please specify below)

1

2

3

Would you accept a country / village location providing you have access to language classes?

Preferences

I would prefer to work with children aged (you can select more than one):

0-1 years:

1-2 years:

3-6 years:

7-10 years:

over 10 years:

I would like to look after (you can select more than one):

1 child:

2 children:

3 children:

4 children:

4+ children:

I am willing to work with (you can select more than one):

single mother:

single father:

family pets:

family of different race:

family of different religion:

family with a smoker(s):

I am willing to do (you can select more than one):

housework:

ironing for the family:

ironing for the children:

cooking for the family:

cooking for the children:

Education/Qualifications

Please list childcare qualifications:

Do you have any experiences with babies and children in the following age ranges (you can select more than one)?

1-2
3-5
6-10

0-11
Disabled

Will you provide references for these?

Do you have knowledge of First Aid?

Knowledge of Languages

Native Language

Other Languages

Language

Level

Years

1

2

3

Employment History

Please describe your last two childcare positions - including duties, approximate working hours, length of employment and reason for leaving:

Position 1:

Referee:

Phone:

Position 2:

Referee:

Phone:

My experience of housework covers:

I am willing to do light housework besides housework for children:

Do you have a current CRB or Police Check:

Hobbies & Interests

My special hobbies and interests are (including playing a musical instrument):

Can you swim?

Driving

Do you have a full driving licence?

Date of Issue

Would you drive during your stay?

Any endorsements?

Do you have any penalty points?

If yes, for what offence:

Have you ever been banned from driving?

If yes, please state date and the reason:

Do you own a car?

If no, do you have access to a car?

Smoking, Drinking, Drugs & Health

Do you smoke?

If yes, how many per day?

If yes, are you prepared not to smoke in your employer's house?

Do you take drugs/medication (you can select more than one):

never:

occassionally:

when necessary:

on a regular basis:

Do you suffer from any mental or physical health problems?

If yes, please give details:

Are you a vegetarian?

Have you got any special diets?

If yes, please give details:

Are you allergic to any of the following (you can select more than one)?

food
animals
insects

plants
medication
chemicals

If you selected any of the above, please give details:

Criminal Convications

Have you ever been convicted of a criminal offence??

If yes, please give details:
 

Mother's Help Agreement

Please read the following and then sign.

I, (please state your full name), have read, understood and accepted the above "Mother's Help Agreement": (please tick)

"Submission of your Mother's Help application form to Sunflower Au-Pair & Mothers Help Agency constitutes acceptance of the above Mother's Help Agreement".