Application form

Application form Elderly Companion

(Formulaire d'inscription

Elderly Companion)

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

Contact information

Gender *

Female Male

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?

Food *

Allergies

Whatever my personal dietary requirements I agree to prepare food for the family/person as they wish *

Yes No

Drivers licence *

Test date

Religion

Practising

Latest certification

Subject

1st aid qualification

Elderly Care qualification

If yes please give details

Interests and Hobbies (sports, musical instruments, activities...) *

Describe your personality *

Preferences

Dates of stay

From *

To *

Country *

England New-Zealand

Location

Large city Town Village

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 *

Yes No Maybe

Willing to work with elderly people with Dementia/alzheimer *

Yes No Maybe

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).