AU PAIR USA

Child Care Reference

Au Pair Instructions: Please give this form to someone you provided child care for. You must submit at least two (2) references from
people who are not members of your family, and these two references should account for at least 200 hours of child care experience. You
must also include both the original reference and any translations as part of your application.
Reference Instructions: Please type or print in black ink. Please be accurate in your assessment of this applicant. Prospective American
host families will read your comments and may contact you for a reference. Please answer all the questions and return this completed
Child Care Reference form to the applicant. You will be contacted by the agency to verify the information you provide.
Thank you for taking the time to share your thoughts with us!

Name of Applicant: Years Known:

Name of Reference: Occupation:

Telephone: Email:
COUNTRY CODE–CITY CODE–PHONE NUMBER

Best way to contact you: Phone Email Best time to contact you: Morning Afternoon Evening

Are you a member of the applicant’s Yes No Do you speak English? Yes No
family in any way? If no, please complete this in your native language.

How do you know this applicant? Friend of Applicant’s Family Personal Friend Other            
Employer Teacher
Work Colleague Relative/Family Member

 CHILD CARE EXPERIENCE?

Applicant has been an au pair a nanny a baby sitter a tutor an employee other             

 ALL REFERENCES MUST ANSWER THE FOLLOWING QUESTIONS.

Please write down the sex and age of the children the applicant cared for (if in a group setting, please write the number of children
and the age range):

AGE OF THE CHILDREN AGE OF THE CHILDREN

NUMBER OF CHILDREN CARED FOR SEX (M/F)
WHEN STARTED WHEN STOPPED

Were any of these children under the age of 2? Yes No

How long have you worked with the applicant? From to Ongoing
MM/DD/YYYY MM/DD/YYYY

Did the applicant live in your home? Yes No

Did the applicant ever drive your children? Yes No

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Child Care Reference (continued)

For the following questions, select all that apply:

How often did he/she provide child care? Daily Weekly Occasionally Seasonally

(Please describe                                                          )

What time of day did he/she provide child care? Morning Day Evenings Overnight

When the applicant cared for children was he/she Alone/Sole caregiver Co-responsible/Multiple caregivers Supervised

Please describe the applicant’s child care duties:

Please comment on any special skills/talents you observed in this applicant:

Please describe the personality and character of this applicant:

This applicant will be placed with an American host family for one year. Please comment on his/her ability to adapt to a new
environment and culture, and how he/she might handle homesickness and stress.

Why would you recommend this applicant for placement as an au pair with an American host family?

Please rate the applicant’s: Excellent Above Average Average Below Average
Maturity
Honesty/Integrity
Flexibility/Adaptability
Ability to communicate
Ability to take on responsibility
Punctuality

The information you submit to InterExchange will be held confidentially, and will only be used by us or disclosed to third parties
as strictly necessary to process the Au Pair’s application, or as otherwise required by law. By submitting this form, you agree that
InterExchange may collect, use, and disclose your personal data to process the Au Pair’s application. Please contact InterExchange at
privacy@interexchange.org for more information.

SIGNATURE OF REFERENCE REQUIRED DATE (MM/DD/YYYY)

OFFICE USE ONLY (Do not write in the area below)

International Cooperator’s Comments:

My signature confirms that I have spoken with the reference listed above and have verified this information, including
the accuracy of the translation,* if any.

International
Cooperator:
PRINT NAME SIGNATURE DATE (MM/DD/YYYY)

* Some referees providing references may not speak or write in English. In such cases, InterExchange allows the referee to fill out this form in their native language
which the au pair then translates. All translations are reviewed and verified by the International Cooperator. Both the original language and translated references are
sent to Au Pair USA.

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