GreatAuPair Childcare Reference Form

GreatAuPair is a full-service au pair agency that has been providing affordable live-in childcare to American
families through carefully screened international au pairs since 2001. As part of our screening process, we
require that each au pair submit references confirming her/his suitability to care for children up to 45
hours per week.

In addition to completing this form, a GreatAuPair representative will be contacting you to verify your
reference. If you do not speak English, please complete the form in your native language. Thank you.

Name of applicant au pair

Name: Jimena Sánchez Gutiérrez

Reference Information

Name:
Contact telephone:
Best time to reach:
Email address:
Street address:
City, Province, Postal Code, Country:

Summary of Work Experience

Please provide the following information about the applicant's experience:

Start Date: 10-3-2020

End Date: 10-3-2021

Type of childcare experience:

Nanny, Day care center Youth group or church Au Pair Summer Camp Babysitting
Mother’s Helper Young Family Members Tutoring Coaching sports Music teacher
Occupational therapist Teacher (part-time) Nurse Teacher (full-time) Special needs

Description of children cared for:

Activities and duties performed

Feeding children Bathing children Playing indoors

Playing outside Homework help Putting children to bed

Arts & crafts projects Preparing baby formula Bottle-feeding baby

Bathing baby Caring for colicky baby Preparing baby food

Playing with baby Spoon-feeding baby Changing diapers/nappies

Teaching baby Potty training

Total number of hours worked over the course of employment? 800

Number of hours involving caring for children under the age of two? 600

Reference Questions

Please describe your experience having this candidate as a caregiver.

Would you recommend him/her to become an au pair in the United States? Yes No

Please explain your answer.

A prospective family may contact you to discuss your reference. Do you feel comfortable speaking English?
Yes No

Printed name

Signature of reference Date

For official use only:

Reference verified by: Rep ID:

Method of verification: Date: