Asia-Bridge-Childcare

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Initial Au Pair Application Form

Email *

Nickname (in English) *

First Name (in English) *

Middle Name (in English)

Family Name (in English) *

Nickname (in Thai) *

First Name (in Thai) *

Middle Name (in Thai)

Family Name (in Thai) *

Phone Number *

Line ID *

Address (on National ID) *

Address (current mailing or living address, if different from ID)

Age *

Birth Year *

Birth Month *

Birth Date *

Do you have a Driver's License? *

Yes

Currently studying.

If yes, what year did you receive a driver's license? (YYYY)

Criminal Record? *

Yes

Criminal Record (if yes please explain)

Medical History

If applicable

List any medical conditions which may affect your ability to work as a nanny

List any current prescription medications

List any current psychological concerns

Allergies to food or pets

References

Please provide two character references who are not relatives (can be friends, coworkers, teachers).

Reference 1 (Name) *

Reference 1 (Relationship to you) *

Reference 1 (Phone) *

Reference 1 (Email) *

Reference 2 (Name) *

Reference 2 (Relationship to you) *

Reference 2 (Phone) *

Reference 2 (Email) *

Education and Certifications

Highest level of education completed, and/or current school attending.

Highest Level of Education Completed

School / University Name *

Level (Highschool, Tech School, Undergraduate, Graduate) *

Degree or Diploma Earned (Highschool, AA, BA, BS, etc) *

Major or specialty (English, Nursing, History, etc) *

Year Completed *

School Currently Attending

If applicable

Current School / University Name

Current Level (Highschool, Tech School, Undergraduate, Graduate)

Degree or Diploma, Future (Highschool, AA, BA, BS, etc)

Current Major or specialty (English, Nursing, History, etc)

Year of Expected Completion

First Aid or CPR Training *

Yes

Formal Childcare Training Certification *

Yes

Formal Childcare Training Certification Description

Any Additional Relevant Training (music, art, coaching, medical)

Hobbies *

Employment History

List relevant employers (if applicable)
- Start date & End date
- Employer name
- Duties / responsibilities

Employment History (Answer field)

Childcare Experience

Select Childcare Experience Type

Teacher

Teacher's Aid

Camp Counselor

Babysitter

Other

Select Experience Ages

Newborn

6-24 months

2-5 years

6-12 years

Teenagers

Childcare Experience Details: feel free to share any details you believe are relevant, ex total hours, child age preferences

Authorization

- I acknowledge that Asia Bridge Childcare Co., Ltd, (the “Agency”) may request a reference check, which may include information on my character, general reputation, education, personal characteristics, driving record, police record, and past employment. I hereby authorize the Agency to obtain any such information.

- I acknowledge that I have read and understand this statement and that, to the best of my knowledge, the information provided in this application is true and correct.

- I agree to release and hold the Agency harmless for any act of the employer. I also agree to hold the Agency harmless of any claim as a result of any placement in which I am a part.

I acknowledge and agree to the above *

Yes

Required

A copy of your responses will be emailed to the address you provided.

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