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Family Contact
Are you a single parent?
Area Coordinator Name:
Family's Last Name: * Email: *
Parent 1's first name: * Parent 2's first name: *
Parent 1's last name: Parent 2's last name
Parent 1's birthdate: Parent 2's birthdate:
Address: * City: *
State: * Zip: *
Phone: * Cell Phone:
 
General Information
What primary language is spoken at home? *
What other language(s) do family members speak?
When would you like the Au Pair to arrive? * mm/dd/yyyy
Are you a US citizen? *
Are you a permanent resident? *
Do you wish to allow Au Pairs whom you place on hold to view your Host Family profile? *
How many children would be requiring Au Pair's care? *
Does your child require an Au Pair with a specialized background with handling special needs challenges and/or any medical conditions? *
How did you find out about CHI Au Pair USA?
If you were referred to CHI Au Pair USA, please enter the name of the person or organization who referred you to us :
Comments:
Program Information / Pre Arranged Aupair
In which Au Pair program are you interested? *
Is this an arranged pre-match with a specific Au Pair? *