Please print off and complete both parts of the Family Registration and return it (by post or e-mail) together with 1 signed copy of the Agency's Terms, a family photograph and £20 Registration Fee to Bergerac Agency's Address.

*Family Details*

Surname:

First Name:

Wife:

Marital Status:

Age Husband:

Wife:

Address:

Home Tel:

Work Tel:

Mobile:

E-Mail:

Husband:

Occupation:

Religion:

Nationality:

Ethnic Origin:

Smoker:

Wife:

Occupation:

Religion:

Nationality:

Ethnic Origin:

Smoker:

Any other languages spoken in your home:

Name of children:

Date of birth:

Sex:

Age:

Name of children:

Date of birth:

Sex:

Age:

Is new baby expected:

Disabilities / Handicaps:

Pets:

Hobbies:

Do you have any domestic help / what type:

Accommodation:

Type:

No. of bedrooms: No. of bathrooms:

Toilets: Garden:

Type of area:

Where / how far is / are the nearest:

College (for English classes):

Town: Shop:

Bus / Train:

*Family Requirements*

Start date:

Earliest: Latest:

Length of stay:

Nationality: Age:

SEX: female / male / couple

VEGETARIAN: essential / preferred / unconcerned

NON-SMOKER: essential / preferred / unconcerned

DRIVER: essential / preferred / unconcerned

Other preferences:

Au-Pair's Accommodation:

Will you provide the Au-Pair with their own:

Television: Car:

Radio / CD Player: Bicycle:

Internet access at home:

*Timetable of Duties*

Please describe how you would expect your Au-Pair to spend a typical day:

Start at: Luch at: Finish at:

Morning Duties:

Afternoon Duties:

Total working hours:

Per Day: Per Week:

Evening baby sitting: Free days:

Free time daily: Pocket money weekly:

If the Au-Pair's parents require a reference, please give a name and address of someone who has known you personally for a period of at least 2 years:

SIGNATURE:…………………………………………


DATE:…………………………………………

*Family Details*

Surname:

First Name:

Wife:

Marital Status:

Age Husband:

Wife:

Address:

Home Tel:

Work Tel:

Mobile:

E-Mail:

Husband:

Occupation:

Religion:

Nationality:

Ethnic Origin:

Smoker:

Wife:

Occupation:

Religion:

Nationality:

Ethnic Origin:

Smoker:

Any other languages spoken in your home:

Name of children:

Date of birth:

Sex:

Age:

Name of children:

Date of birth:

Sex:

Age:

Is new baby expected:

Disabilities / Handicaps:

Pets:

Hobbies:

Do you have any domestic help / what type:

Accommodation:

Type:

No. of bedrooms: No. of bathrooms:

Toilets: Garden:

Type of area:

Where / how far is / are the nearest:

College (for English classes):

Town: Shop:

Bus / Train:

*Family Requirements*

Start date:

Earliest: Latest:

Length of stay:

Nationality: Age:

SEX: female male couple

VEGETARIAN: essential preferred unconcerned

NON-SMOKER: essential preferred unconcerned

DRIVER: essential preferred unconcerned

Other preferences:

Au-Pair's Accommodation:

Will you provide the Au-Pair with their own:

Television: Car:

Radio / CD Player: Bicycle:

Internet access at home:

*Timetable of Duties*

Please describe how you would expect your Au-Pair to spend a typical day:

Start at: Luch at: Finish at:

Morning Duties:

Afternoon Duties:

Total working hours:

Per Day: Per Week:

Evening baby sitting: Free days:

Free time daily: Pocket money weekly:

If the Au-Pair's parents require a reference, please give a name and address of someone who has known you personally for a period of at least 2 years:

SIGNATURE:…………………………………………


DATE:…………………………………………

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