Application form

Merci de compléter ce document EN ANGLAIS. L'envoi par mail se fait automatiquement à la fin.
Contact information
Gender*

FemaleMale
First name*
Surname*
Mobile (+33)*
Skype*
landline (+33)*
Email*
Address line 1*
Address line 2
Town*
postcode*
Country*
Personal information
Nationality*
DOB*
Current situation*
Mother tongue*
Other languages spoken
Level of HOST country language*
Smoker*
If smoker, how many cigarettes do you smoke a day or a week?
Food*
Allergies
Whatever my personal dietary requirements I agree to prepare food for the family/person as they wish*

YesNo
Drivers licence*
Test date
Religion
Practising
Latest certification
Subject
1st aid qualification
Elderly Care Qualification

YesNo
If yes please give details
Interests and Hobbies (sports, musical instruments, activities...)*
Describe your personality*
Preferences
Dates of stay
From*
To*
Country*

EnglandIrelandNew-Zealand
Location

Large cityTownVillage
Do you wish to attend languages classes during your stay
Pets you are not willing to live with / look after
Housework tasks willing to do (tâches ménagères prêt(e) à effectuer)
Vacuming (Aspirateur)Laundry (Gérer les lessives)Cleaning (nettoyage sols, cuisine, sdb...)Basic cooking (Faire la cuisine)Dusting (Poussières)Ironing (Repassage)Basic gardening (Jardinage basic)
(Ces tâches font souvent partie du rôle du elderly Companion au pair, nous vous conseillons d'être le plus flexible possible)
Care tasks willing to do (tâches de soutien prêt(e) à effectuer)
Lifting elderly person (soulever/porter)Personal hygiene care (aider aux soins/toilette)Help to get dressed (aider à s'habiller)take elderly person to their activities/appointments (amèner aux rdv)
(Ces tâches font dès fois partie du rôle du elderly Companion au pair)
Willing to work with elderly people with limited mobility*

YesNoMaybe
Willing to work with elderly people with Dementia/alzheimer*

YesNoMaybe
Employment experience
Elderly care experience (Expérience avec les personnes âgées)
Experience 1
Dates and duration
Age (approx) and gender of the elderly person
Tasks and activities
Experience 2
Dates and duration
Age and gender of the elderly person
Tasks and activities
Other employment or relevant experience
Experience 1
Dates and duration
Job title and name of company
Job description
Experience 2
Dates and duration
Job title and name of company
job description
Experience 3
Dates and duration
Job title and name of company
Job description
Je certifie l’exactitude des informations et documents transmis dans le cadre de mon dossier d’inscription et j’accepte que l’Agence Pipelettes conserve ces données pour une durée de 5 ans maximum dans l’éventualité d’un nouveau placement ou pour raison administrative (délivrance d’attestation de placement par exemple).
Should be Empty: