Tu solicitud Au Pair en los Estados Unidos

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PERSONAL REFERENCE
The applicant presenting you with this form is a candidate for the AuPairCare program. If accepted, he/she will
spend a year with an American family taking care of and being responsible for the children in this family.
NOTE: This ref erence must be compl et ed by a NON-RELAT IVE and wil l be verif ied by an AuPairCare
represent at ive. You may be cont act ed t o verif y t his ref erence.
1. Name of applicant:_______________________________________________________________________________
2. How long have you known this applicant? __________________________________________________________
3. How do you know this applicant?
Ⱥ Employer
Ⱥ Neighbor
Ⱥ Friend
Ⱥ Colleague
Ⱥ Teacher
Ⱥ Other _____________________________________
4. How would you describe this person’s character?
Ⱥ Active
Ⱥ Family-oriented
Ⱥ Adaptable
Ⱥ Flexible
Ⱥ Creative
Ⱥ Humorous
Ⱥ Efficient
Ⱥ Independent
Ⱥ
Ⱥ
Ⱥ
Ⱥ
Open-minded
Outgoing
Polite
Positive
Ⱥ
Ⱥ
Ⱥ
Ⱥ
Sociable
Sporty
Warm-hearted
Other ______________________
5. Please describe why you believe the applicant is suitable for the AuPairCare program. List any relevant
skills and abilities the applicant has demonstrated:
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
6. Do you recommend this applicant for the AuPairCare program? Ⱥ Yes Ⱥ No Please explain:
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
7. Additional comments on the applicant’s character:
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
8. Reference Information:
Name: _____________________________________________________________________________________________
Address: ___________________________________________________________________________________________
Signature: ____________________________________________________________ Date: ______/______/________
9. May a prospective host family call you? Ⱥ Yes Ⱥ No, I am uncomfortable speaking English.
Email Address: _______________________________________
Daytime Phone: (011) ____________________________
Country Code/Local Number
Evening Phone: (011) _____________________________
Country Code/Local Number
For Office Use Only
Verified by: ___________________________________________________ Date: _____/_____/_____
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Historial Médico Verificado por un Médico
Nota al Médico: La persona que le solicita este certificado, ha solicitado una plaza para la posición de au pair en EE.UU. Si el/la candidato/a es
aceptado, el/ella pasará un año con una familia estadounidense cuidando los niños de la familia y siendo responsable por ellos. Es importante que las
personas a quiénes confiamos este trabajo gocen de buena salud. Por favor, proporcione su historial médico detalladamente y añada
cualquier información que pueda ser necesaria.
Nombre del paciente:
Edad:
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Altura:
_ Fecha de nacimiento (mes/dia/ año):
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Peso: _
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1. ¿Ha padecido este paciente alguna vez de o ha sido diagnosticado con alguno de los siguientes? Por favor indíquelo, haciendo una cruz en ³Si´ y
³No´ para cada condición:
Alguna enfermedad o anormalidad de:
Salud general:
Si No
Ƒ Ƒ Anorexia
Ƒ Ƒ Alergias
Ƒ Ƒ Bulimia
Ƒ Ƒ Varicela
Ƒ Ƒ Diabetes
Ƒ Ƒ Epilepsia
Ƒ Ƒ Hernia
Ƒ Ƒ HIV/Sida
Ƒ Ƒ Hepatitis
Ƒ Ƒ Sarampión
Si No
Ƒ Ƒ Meningitis
Ƒ Ƒ Paperas
Ƒ Ƒ Rubéola
Ƒ Ƒ Fiebre Escarlata
Ƒ Ƒ Tos severa o persistente
Ƒ Ƒ Dolores de cabeza serios o
persistentes
Ƒ Ƒ Tuberculosis
Ƒ Ƒ Fiebre tifoidea
Ƒ Ƒ Ulcera
Ƒ Ƒ Vertigo/ Mareo
Si No
Ƒ Ƒ Asuntos genito-urinarios
Ƒ Ƒ Disturbios mentales o nerviosos
Ƒ Ƒ ¿Esta la paciente embarazada?
Ƒ Ƒ ¿Tiene el/la paciente una minusvalía física?
Ƒ Ƒ ¿Tiene el/la paciente una
enfermedad contagiosa?
Ƒ Ƒ ¿Tiene el/la paciente una dependencia de
alcohol o de drogas?
Ƒ Ƒ ¿Sufre el/la paciente de ataques de pánico?
Ƒ Ƒ ¿Fuma el/la paciente?
Ƒ Ƒ Otros::
Si No
Ƒ Ƒ Sistema endocrino o cardiovascular
Ƒ Ƒ Huesos, articulaciones, o locomotora
Ƒ Ƒ Cerebro o sistema nervioso
Ƒ Ƒ Oído o audición
Ƒ Ƒ Ojos o visión
Ƒ Ƒ Corazón
Ƒ Ƒ Pulmones o sistema respiratorio
Ƒ Ƒ Otros órganos abdominales
Ƒ Ƒ Estomago o digestiva
Ƒ Ƒ Amígdala, nariz o garganta
Si ha indicado ³Si´en alguna de la condiciones mencionadas arriba, por favor explique en detalle y indique el año en que la(s) enfermedad(es) ocurrió
(/ocurrierón). Si el año exacto es desconocido, por favor indique un año aproximado:
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2. Por favor liste todas las inoculaciones/ vacunas/ inmunizaciones que han sido dadas a este/a paciente de adulto/a y el mes y año aproximados:
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3. ¿Ha sido este/a paciente alguna vez hospitalizado? Ƒ SiƑ No
Se si, por favor explique:
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4. ¿Ha sido este/a paciente tratado en los últimos dos años de alguna condición médica? Ƒ SiƑ No
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Se si, por favor explique:
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5. ¿Toma el/la paciente alguna medicación con regularidad (excluyendo anticonceptivos)?Ƒ SiƑ No
Se si, por favor explique:
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6. ¿Sufre este/a paciente de alguna condición pre-existente?Ƒ SiƑ No
Se si, por favor explique:
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7. ¿Ha recibido este/a paciente alguna vez asesoramiento psicológico? Ƒ SiƑ No
Se si, por favor explique:
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Rev. 04/2013
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8. ¿Tiene el/la paciente un historial o síntomas de una disturbio alimentar, tal y como la anorexia, bulimia u otras condiciones semejantes? Ƒ SiƑ No
Se si, por favor explique:
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9. ¿Presenta el/la paciente un historial o síntomas de una anormalidad nerviosa, emocional o mental (i.e. neurosis, depresión nerviosa,
fatiga nerviosa, pesadillas recurrentes, ataques de pánico, etc.)?Ƒ SiƑ No
Se si, por favor explique:
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10. ¿Sufre este/a paciente de alguna condición crónica (i.e. asma, artritis, diabetes, epilepsia, fatiga crónica, etc.)?Ƒ SiƑ No
Se si, por favor explique:
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11. ¿Ha sido el/la paciente alguna de vez victima de abuso físico o sexual? Ƒ SiƑ No
Se si, por favor explique:
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12. ¿Hay alguna razon por la cual este/a paciente no debería cuidar a niños? Ƒ SiƑ No
Se si, por favor explique:
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13. ¿Hay cualquier otra cosa que le gustaría decir sobre este/a paciente?Ƒ SiƑ No
Se si, por favor explique:
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14. En mi opinión de experto, el estado general de salud del paciente es:
Ƒ Excelente
Ƒ Buena
Ƒ Regular
Ƒ Pobre
Yo, el abajo firmante, he hecho un examen físico riguroso al/ a la paciente y revisto su historial medico.
Yo certifico que la información arriba mencionada es completamente correcta en mi conocimiento.
Nombre del médico:
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Número de teléfono:
Firma:
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Fecha (mes/ dia/ año):
Rev. 04/2013
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Sello del medico aqui
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2
2014 AU PAIR AGREEMENT
This AuPairCare Au Pair Agreement (t he “ Agreement ” ) is ent ered int o bet ween AuPairCare, a Calif ornia Corporat ion and “ Au Pair” (f irst
and last name of Au Pair) ________________________of (Cit y) ______________________, (Count ry) __________________” . Au Pair has
f ully read t his Agreement and agrees t o t he t erms and condit ions cont ained herein. “ Host Family” is t he f amily in t he Unit ed St at es
wit h whom Au Pair has agreed t o mat ch, and wit h whom Au Pair will live and work.
A. General Provisions
Au Pair is hereby advised and acknowledges t hat t he part ies agree as f ollows:
1.
Au Pair will abide by t he t erms and condit ions of t his Agreement f or t he durat ion of Au Pair’ s part icipat ion in t he AuPairCare program,
unless and unt il t his Agreement is replaced or modif ied by a subsequent writ t en agreement execut ed by AuPairCare and Au Pair.
2.
Au Pair is hereby advised and acknowledges t hat all Au Pairs are part icipant s in a cult ural exchange program, and agrees t o comply wit h
all of t he regulat ions published by U. S. Depart ment of St at e in 22 CFR Part 514, as t he same may be amended f rom t ime t o t ime in t he
f ut ure (“ t he Regulat ions” ). Said regulat ions can be f ound by visit ing: ht t p: / / j 1visa. st at e. gov/ programs/ au-pair
3.
Au Pair underst ands t heir right s as visa part icipant under t he Wilberf orce Traf f icking Vict ims Act . Said right s and resources f or can be
f ound by visit ing: ht t p: / / t ravel. st at e. gov/ cont ent / visas/ english/ general/ right s-prot ect ions-t emporary-workers. ht ml
4.
Au Pair represent s t hat all inf ormat ion provided t hroughout t he applicat ion process is t rue and t hat no relevant inf ormat ion has been
excluded or misrepresent ed in t he applicat ion process and document s, including represent at ion of t he level of English prof iciency,
healt h and/ or childcare experience. Au Pair agrees t hat all such disclosures will be f ull and accurat e, up t o and t hrough t he dat e of
depart ure f rom Au Pair’ s count ry of origin.
5.
Au Pair agrees t o complet e all visa screening requirement s in accordance wit h t he inst ruct ions given and will be responsible f or
obt aining a valid passport and complying wit h all vaccinat ions and immunizat ion requirement s.
6.
Au Pair agrees t o immediat ely amend any disclosures should new inf ormat ion become available t o Au Pair in any regard or at any t ime
of part icipat ion in t he program. Au Pair represent s t hat s/ he will personally conduct all writ t en and phone correspondence wit h Host
Family during t he int erviewing process. Au Pair underst ands t hat exaggerat ion or f alsif icat ion of any applicat ion inf ormat ion by Au Pair,
ref erences or Originat ing Exchange Organizat ion may result in immediat e dismissal f rom t he program and ret urn t o Au Pair’ s home
count ry at Au Pair’ s expense.
7.
AuPairCare has t he exclusive right t o det ermine suit abilit y of Au Pair t o part icipat e in t he program bot h bef ore and during part icipat ion
in t he program. Au Pair agrees t hat in det ermining suit abilit y, AuPairCare may make inquiries t o t hird part ies about Au Pair, including
but not limit ed t o medical personnel and insurance agencies ot herwise covered by f ederal HIPAA regulat ions.
8.
Au Pair underst ands t hat t hey cannot be married, engaged t o be married or have children of t heir own and part icipat e in AuPairCare’ s
au pair program.
9.
Au Pair is not an employee, agent or independent cont ract or of AuPairCare, and AuPairCare does not exercise dominion or cont rol over
t he act ions of t he Host Family.
B. Fees and Program Costs
10.
Part icipat ion in t he AuPairCare program requires Au Pair t o pay a non-ref undable program f ee t o Originat ing Exchange Organizat ion.
11.
Originat ing Exchange Organizat ion may charge Au Pair addit ional f ees t o cover t heir administ rat ive cost s in promot ing t he AuPairCare
program and processing au pair applicat ions. The f ees may include, but are not limit ed t o, an applicat ion f ee, processing f ee, handling
f ee, and int erview f ee.
These f ees may vary across Originat ing Exchange Organizat ions.
AuPairCare assumes no dut ies or
responsibilit ies f or any act s or omissions of t he Originat ing Exchange Organizat ion regarding addit ional f ees.
12.
Au Pair will be responsible f or addit ional cost s, including but not limit ed t o, baggage check f ees f or arrival and ret urn f light s, personal
expenses while at t he Au Pair arrival orient at ion, medical expenses not covered by insurance and all incident als and personal expenses
while on t he program. Au Pairs should be prepared t o cover t hese cost s.
13.
Au pair will pay all applicable f ees t o Originat ing Exchange Organizat ion bef ore beginning t ravel t o t his Unit ed St at es. Au Pair may not
under any circumst ances solicit f unds f rom Host Family f or t o cover personal cost s of program, including but not limit ed t o f ees due t o
t he Originat ing Exchange Organizat ion, cost s associat ed wit h securing a visa, or incident al t ravel cost s.
14.
Au Pair agrees t hat s/ he has adequat e f inancial resources t o sat isf y all obligat ions as an AuPairCare Au Pair, including payment f or a
ret urn f light if Au Pair does not successf ully complet e t he program.
C. Au Pair Cancellations/ Flight Change Requests
15. Au pair agrees t o pay a $300. 00 USD cancellat ion f ee, plus the actual cost of international and/ or domestic airfare (if t ravel has been
arranged), in t he event he/ she cancel f rom t he program af t er mat ching wit h a f amily but prior t o arrival at t he host f amily home.
16. Au pair agrees t o pay a $300. 00 USD change f ee and any applicable airfare penalties, in t he event he/ she request s t o change t heir
arrival dat e.
D. Responsibilities
17.
Au Pair underst ands t hat during t he f irst t hree (3) days of an au pair’ s st ay in t he home, a parent or anot her responsible adul t shall
remain in t he home t o f acilit at e t he adj ust ment of t he au pair int o t he f amily, household and communit y.
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Au Pair’ s Initials__________
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18.
Au Pair agrees t o perf orm childcare services and light housekeeping relat ed t o childcare t hat shall not exceed f ort y-f ive (45) hours per
week, f ive and one half (5 1/ 2) days per week, wit h a maximum of t en (10) hours per day. Au Pair will have one f ull weekend of f per
mont h (Friday evening t o Monday morning). If a disput e arises as t o any of t hese limit s or requirement s, AuPairCare shall resol ve said
disput e, and it s decision shall be f inal.
19.
Au Pair’ s responsibilit ies will be limit ed t o childcare and child-relat ed t asks f or t he Host Family. This may include dut ies such as general
supervision, preparing and cleaning up af t er children’ s meals, st raight ening children’ s rooms, doing children’ s laundry, preparing t he
children f or school, assist ing wit h homework, and being present when children are sleeping. The Au Pair’ s responsibilit ies wil l not
include heavy housework, yard work or ot her non-child relat ed labor f or t he household. If a disput e arises concerning t he scope of t he
Au Pair’ s responsibilit ies, AuPairCare shall resolve said disput e, and it s decision shall be f inal.
20.
Au Pair underst ands t hat U. S. Depart ment of St at e regulat ions prohibit Au Pair employment beyond t he au pair arrangement wit h t he
Host Family. Au Pair may not undert ake any ot her paid work while in t he U. S. , including babysit t ing f or Host Family f or ext ra pay
beyond t he 45 hour weekly limit , babysit t ing f or ot her f amilies, or t ut oring language st udent s.
21.
Au Pair is hereby advised and underst ands t hat if t here is an infant under the age of two years old in t he household, t he au pair must
have 200 hours of documented experience working with children under the age of two. Such document ed experience shall be
verif ied by AuPairCare prior t o au pair placement .
22.
Au Pair underst ands t hat in t he event t here is an infant under the age of three months in t he household, a parent or ot her responsible
adult shall be present in t he home at all t imes, and Au Pair shall not be the sole caregiver for that child at any time.
23.
Au Pair agrees t o perf orm t he childcare responsibilit ies t o t he best of his/ her abilit y, and make every ef f ort t o act as a caring,
responsible Host Family member.
E. Behavior and Comportment
24.
Au Pair agrees t o abide by Host Family rules as t hey are det ermined by t he Host Family, and will behave as a responsible member of t he
Host Family at all t imes. If a disput e arises concerning t he Host Family rules, AuPairCare shall resolve said disput e, and it s decision
shall be f inal. Au Pair underst ands t hat Host Family is not required t o provide access t o a car, personal phone line, personal t elevision,
comput er or ot her perks.
25.
If Au Pair is expect ed or permit t ed t o drive t he f amily car(s), Au Pair will obtain a valid international driver’ s license prior to arrival
in the United States, and if required by law, obtain a U. S. driver’ s license at his/ her own expense . Failure t o do so may result in
t erminat ion f rom t he program.
26.
Au Pair underst ands t hat if s/ he is expect ed or permit t ed t o drive t he f amily car(s), t he Host Family must provide suf f icient aut omobile
insurance t o comply wit h all applicable laws, and which insurance shall in no event cover less t han $10, 000 in medical coverage. Au pair
underst ands t hat it is t heir responsibilit y t o ensure said policy is act ive t hroughout t heir program part icipat ion, if t hey will be expect ed
or permit t ed t o drive. Au Pair will not be responsible f or payment of any aut omobile insurance deduct ibles t hat exceed $250 per
accident . Au Pair agrees never t o use t he car(s) wit hout t he express permission of Host Family or t o use t he car f or purposes not
approved by t he Host Family.
27.
Au Pair agrees t o f ollow all local and st at e laws concerning cell phone use and driving, and at a minimum agrees t o not use a cell phone
while driving a mot or vehicle unless it has been connect ed t o a hands-f ree device AND he/ she has received permission f rom his/ her Host
Family t o use said equipment . Failure t o adhere t o t his agreement may result in immediat e t erminat ion f rom t he program.
28.
Au Pair agrees not t o web surf , send, or read t ext -based communicat ion on elect ronic wireless communicat ions devices, such as cell
phones, while driving a mot or vehicle. Failure t o adhere t o t his agreement may result in immediat e t erminat ion f rom t he program.
29.
Au Pair agrees not t o hit chhike at any t ime, due t o t he dangerous nat ure of hit chhiking in t he Unit ed St at es.
30.
Au Pair agrees t o exercise sound j udgment and caut ion while part icipat ing in Int ernet -based communit ies, dat ing and social net working
websit es such as Facebook, Orkut , MySpace or ot her sit es. Au Pair underst ands t hat Host Family inf ormat ion, including but not limit ed
t o phone numbers, addresses, f amily names, inf ormat ion about Host Family children, or phot os of Host Family home and household
members may not be post ed online by Au Pair, wit hout t he Host Family’ s prior consent .
31.
Au Pair agrees not t o send, receive or view inappropriat e cont ent (sexual or violent ) in t he host f amily home, or out side of t he home
using t he host f amily’ s equipment (i. e. comput er, cell phone, handheld device, t ablet , DVD player, t elevision, et c. ) by means of , but
not limit ed t o: live video, phot os, pre-recorded videos, inst ant messages, sext ing/ t ext ing, social media post s/ updat es. Failure t o adhere
t o t his agreement may result in immediat e t erminat ion f rom t he program.
32.
Au Pair agrees not t o buy, possess or consume any cont rolled or illegal subst ances, except t hose prescribed by a physician. Au Pair
understands that the legal drinking age in the United States is age 21, and that the legal ramifications of underage drinking in the
United States are serious and can result in immediate termination from the AuPairCare program . Au Pair agrees not t o consume
alcoholic beverages at any t ime if Au Pair is under t he legal drinking age of 21. If Au Pair is of legal drinking age, Au Pair agrees not t o
excessively consume alcoholic beverages at any t ime. Au Pair agrees never t o drive an aut omobile af t er consuming alcoholic beverages.
Au Pair agrees never to consume alcoholic beverages while on duty caring for Host Family children. As wit h all ot her t erms of t his
Agreement , if Au Pair violat es t his t erm of t he Agreement , AuPairCare may in it s sole discret ion t erminat e Au Pair’ s part icipat ion in t he
program and immediat ely repat riat e Au Pair t o his/ her home count ry at Au Pair’ s expense.
33.
Au Pair agrees t o abide by all local, st at e and f ederal laws. If Au Pair is arrest ed and/ or is in police cust ody under suspicion of
commit t ing a crime, AuPairCare will not arrange or pay f or legal assist ance or represent at ion f or Au Pair. Au Pair will be responsible f or
resolving any legal mat t ers independent ly and wit hout t he assist ance of AuPairCare and it s st af f . As wit h all ot her t erms of t his
Agreement , if Au Pair violat es t his t erm of t he Agreement , AuPairCare may in it s sole discret ion t erminat e Au Pair’ s part icipat ion in t he
program and immediat ely repat riat e Au Pair t o his/ her home count ry at Au Pair’ s expense.
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34.
Au Pair underst ands t hat t he AuPairCare program is a smoke f ree program and agrees not t o smoke while part icipat ing in t he AuPairCare
program. This includes, but is expressly not limit ed t o, smoking in or around t he Host Family home. As wit h all ot her t erms of t his
Agreement , if Au Pair violat es t his t erm of t he Agreement , AuPairCare may in it s sole discret ion t erminat e Au Pair’ s part icipat ion in t he
program and immediat ely repat riat e Au Pair t o his/ her home count ry at Au Pair’ s expense.
35.
Au Pair underst ands and agrees t hat monit oring and recording devices, including but not limit ed t o nanny cams may be implement ed in
common areas of t he Host Family home in order t o monit or Au Pair’ s perf ormance and int eract ion wit h t he child(ren) whom Au Pair is
caring f or, and consent s t heret o and waives any and all claim of privacy right s wit h respect t heret o.
F. Compensation and Financial Responsibility
36.
Au Pair will receive room and board in t he f orm of meals and a suit able privat e bedroom in Host Family’ s home, which has been
approved by a local AuPairCare represent at ive.
37.
Au Pair will receive a weekly stipend in accordance wit h t he U. S. Depart ment of St at e Regulat ions in t he amount of $195. 75. Said
st ipend shall be paid by t he Host Family on t he same mut ually agreed upon day each week in t he payment met hod chosen by t he Host
Family, and cannot be wit hheld f or any reason.
38.
Au Pair will receive two calendar weeks paid vacation (10-days) , t o be t aken at mut ually agreed upon t imes. Vacat ion days shall
accrue on t he basis of one day per mont h f rom t he beginning of Au Pair’ s t hird mont h in t he U. S. During Au Pair's ext ension program,
Host Family will provide 9-mont h and 12-mont h ext ension Au Pair wit h t wo calendar weeks (10-days) of paid vacat ion, t o be t aken at
mut ually agreed upon t imes. A 6-mont h ext ension Au Pair will receive one calendar week (5-days) of paid vacat ion. Vacat ion days shall
accrue on t he basis of one day per mont h f rom t he beginning of t he Au Pair’ s t hirt eent h mont h in t he U. S. If any disput es arise
concerning vacat ion issues, AuPairCare shall resolve said disput e, and it s decision shall be f inal.
39.
Au Pair understands that he/ she is not entitled to paid or unpaid holiday time-off.
40.
Au Pair will receive subsidy of educational costs f rom t he Host Family as out lined in t he “ Training and Educat ion Requirement s”
sect ion of t his document .
41.
Upon successful completion of the program, Au Pair will receive a return flight airline ticket from AuPairCare t o Au Pair’ s home
count ry. Au Pair will be responsible f or planning and paying f or t ravel f rom t he int ernat ional dest inat ion airport t o Au Pair’ s f inal
dest inat ion in home count ry. Au Pair underst ands t hat in t he event Au Pair does not elect t o use t he ret urn air t icket provided by
AuPairCare f or any reason, no ref und, credit , or t ravel voucher will be provided.
42.
Au Pair underst ands t hat in 1994, t he U. S. Depart ment of Labor det ermined t hat t he au pair st ipend const it ut es "wages" because an
employer-employee relat ionship exist s bet ween t he au pair and t he Host Family. Au Pair’ s wages are essent ially in t he nat ure of
household employment , and t heref ore Au Pair is required to file U. S. individual tax returns, even if no taxes are due .
43.
Au Pair is responsible for complying with any Federal or state labor and/ or income tax laws t hat may apply t o Au Pair. AuPairCare
does not provide legal advice regarding any such laws and is not responsible f or inf orming Au Pair of , or overseeing compliance wit h, any
such labor laws, including but not limit ed t o Worker’ s Compensat ion laws and/ or income or ot her t ax laws which may vary f rom st at e t o
st at e, and are subj ect t o change f rom t ime t o t ime.
44.
Au Pair is wholly responsible for personal expenses and management of personal finances. AuPairCare shall not be responsible f or
any personal bills incurred by t he Au Pair or Host Family, such as (wit hout limit at ion) t elephone bills, aut omobile expenses, t ravel
expenses, and/ or healt h expenses not covered by insurance . Accordingly, Au Pair agrees not t o seek payment or assist ance in
recovering any such expenses or cost s f rom AuPairCare.
G. Travel and Accident Insurance
45.
Au Pair will receive t ravel and accident insurance provided by AuPairCare t hrough a t hird-part y insurance carrier, and such coverage
cont ains limit at ions and exclusions. Au Pair agrees t o review t he scope of said coverage and t he limit at ions and exclusions cont ained
t herein prior t o arrival in t he Unit ed St at es.
Said inf ormat ion can be accessed on AuPairCare’ s websit e:
ht t p: / / www. aupaircare. com/ current -au-pair/ insurance. Au Pair is advised and agrees t hat any disput es pert aining t o coverage issues
are st rict ly bet ween Au Pair and t he t hird-part y insurance company, and agrees t hat AuPairCare is not responsible f or any coverage
issues and/ or disput es. Not e: This sect ion [ 43] does not appl y t o au pairs recruit ed by Originat ed Exchange Organizat ion; STS St udent
Tr avel School s AB. STS Travel School AB au pairs shoul d ref er t o sect ion [44].
46.
If recruit ed by Originat ing Organizat ion, STS St udent Travel Schools AB, Au Pair will receive t ravel and accident insurance provided by
STS St udent Travel Schools AB t hrough a t hird-part y insurance carrier, and such coverage cont ains limit at ions and exclusions. Au Pair
agrees t o review t he scope of said coverage and t he limit at ions and exclusions cont ained t herein prior t o arrival in t he Unit ed St at es.
Said inf ormat ion can be accessed by visit ing www. f alck. com/ t ravelcare. Au Pair is advised and agrees t hat any disput es pert aining t o
coverage issues are st rict ly bet ween Au Pair and t he t hird-part y insurance company, and agrees t hat AuPairCare is not responsible f or
any coverage issues and/ or disput es.
47.
Au Pair understands that pre-existing medical conditions will not be covered by the third-party travel and accident insurance.
48.
Au Pair understands that the dental insurance provided to them only covers inj uries that are the result of an accident, and does
not cover the cost of standard dental treatment. It is t heref ore import ant f or Au Pair t o receive a t horough dent al examinat ion so
t hat no unexpect ed complicat ions arise during t he period of residence abroad.
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49.
Au Pair represent s t hat t he medical hist ory provided t o AuPairCare is t rue, and gives f ull consent t o release all medical and psychiat ric
hist ory inf ormat ion t o pot ent ial host f amilies.
50.
If Au Pair’ s medical condition changes (including pregnancy), bet ween t he t ime of signing t his document and Au Pair’ s depart ure t o
t he U. S. , Au Pair underst ands t hat s/ he is required t o not if y AuPairCare and resubmit anot her Physician Verif ied Medical Hist ory
document prior t o arrival. As wit h all ot her t erms of t his Agreement , if Au Pair violat es t his t erm of t he Agreement , AuPairCare may in
it s sole discret ion t erminat e Au Pair’ s part icipat ion in t he program and immediat ely repat riat e Au Pair t o his/ her home count ry at Au
Pair’ s expense.
51.
Au Pair agrees t hat AuPairCare and/ or it s af f iliat es or agent s may, wit hout liabilit y or expense t o t hemselves, t ake what ever act ion t hey
deem appropriat e wit h regard t o Au Pair’ s healt h and saf et y, including, but not limit ed t o having Au Pair hospit alized f or medical
services and t reat ment . Au Pair f urt her agrees t hat if hospit alizat ion is not f easible f or any reason, AuPairCare and/ or it s af f iliat es or
agent s may rely upon t he advice and medical j udgment of local medical st af f in order t o make a decision as t o what is in Au Pair’ s best
int erest s. Au Pair hereby gives f ull consent t o be medically t reat ed pursuant t o t he t erms of set f ort h herein, and/ or t o undergo any
t reat ment , including but not limit ed t o surgery, which is det ermined t o be necessary t o Au Pair’ s healt h and well-being during Au Pair’ s
st ay abroad.
52.
Insurance provided by AuPairCare is valid f or 365 days f rom Au Pair’ s arrival in t he US and Au Pair accept s responsibilit y f or payment of
an ext ension f ee t o receive any coverage af t er t he 365 days.
53.
Au Pair accept s f ull responsibilit y f or any medical expenses which are not covered by t he insurance policy provided by AuPairCare
t hrough a t hird part y.
54.
In t he event Au Pair displays a serious medical condit ion t hat in t he j udgment of AuPairCare prevent s t he Au Pair f rom cont inuing in t he
program (including but not limit ed t o ment al illness, subst ance abuse, eat ing disorders and/ or pregnancy), whet her said condit ion is
pre-exist ing or new, Au Pair will be t erminat ed f rom t he au pair program at AuPairCare’ s sole discret ion.
H. Training and Education Requirements
55.
Au Pair agrees t o complet e 32 hours of t raining prior t o arrival at Host Family home, as required by t he Unit ed St at es Depart ment of
St at e. To meet t his requirement , Au Pair will attend in full the Au Pair Academy training program upon arrival in the United States
and complete a required Pre-Departure Proj ect as def ined by AuPairCare.
56.
Au Pair understands that all 12-month program Au Pairs are required to attend courses of study at an accredit ed U. S. post secondary inst it ut ion f or a minimum of six (6) credit hours or it s equivalent in credit hours. Host Family will provide Au Pair wit h t ime
of f and provide adequat e t ransport at ion t o and f rom t he place of inst ruct ion, and will pay t uit ion up t o a maximum of $500 per au pair
per year. Local AuPairCare Area Direct ors are available t o provide inf ormat ion about t his requirement and accept able schools;
however, it is Au Pair’ s responsibilit y t o plan appropriat ely so t hat s/ he is able t o f ulf ill t he requirement .
57.
Au Pair underst ands t hat all courses shall be t aken at mut ually agreed upon t imes wit h t he Host Family.
Au Pair shall be responsible
f or cost s associat ed wit h such educat ional st udy t hat exceed t he amount paid by Host Family. Au Pair agrees t o submit an Educat ion
Plan at t he st art of t he program year t o out line coursework plans. Au Pair agrees t o provide document at ion of coursework compl et ion
t owards t he end of t he program year. In t he event Au Pair does not complet e t he educat ional requirement , Au Pair will be ineligible t o
apply f or an ext ension of t he au pair program.
I. Extension of Au Pair Program
58.
Au Pair is hereby advised and underst ands t hat au pairs wishing t o part icipat e on t he Ext ension Program must submit t heir applicat ion
on or bef ore AuPairCare’ s published deadline dat e and AuPairCare does not guarant ee t hat AuPairCare or t he Depart ment of St at e will
approve any ext ension request or t hat au pairs who choose t o self -ext end will mat ch wit h a new Host Family.
59.
Au Pair is hereby advised and underst ands t hat au pairs part icipat ing on t he ext ension program will receive an updat ed DS-2019 f orm
t hat ref lect s t he 6, 9, or 12-mont h program ext ension. Alt hough au pairs will have a valid DS-2019 f orm, t he J-1 visa in his/ her passport
may have expired during t he f irst 12-mont hs of st ay in t he U. S. Any t ravel out side t he U. S. is at t he au pair’ s own risk, and AuPairCare
cannot assist Au Pair or Host Family in resolving any visa concerns t hey may encount er.
60.
Au Pair underst ands t hat Extension Au Pairs are required to repeat the educational component of t he program during t he ext ension
t ime as f ollows: The educat ional component f or a 6-mont h ext ension is not less t han t hree (3) semest er hours of academic credit or it s
equivalent . Host Family will cont ribut e up t o $250 t oward t he educat ional component . The educat ional component f or a 9 and 12mont h ext ension is not less t han six (6) semest er hours of academic credit or it s equivalent . Host Family will cont ribut e up t o $500
t oward t he educat ional component .
61.
Au Pair is hereby advised t hat by ext ending t heir program t hey must complet e t he new program t erms in order t o be eligible f or a ret urn
f light home arranged by AuPairCare. In t he event t hat t he au pair chooses t o leave t he program early, he/ she will be responsibl e f or
booking and paying f or t heir own ret urn f light home.
J. Problem Resolution and Placement Changes
62.
Au Pair is living as a member of a Host Family and is not under cont inual oversight or cont rol of AuPairCare st af f . Theref ore, it is Au
Pair’ s responsibilit y t o prompt ly advise AuPairCare of any signif icant problems or event s t hat occur during t he program, including but
not limit ed t o Au Pair’ s healt h, saf et y, welf are, or adj ust ment t o f amily, cult ure, or languages. For purposes of t his Agreement , a
“ signif icant event or problem” is any change in Au Pair’ s circumst ance t hat may af f ect an au pair’ s well-being and/ or living sit uat ion.
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63.
Au Pair is hereby advised and underst ands t hat AuPairCare requires an initial adj ustment period of 60 days following Au Pair’ s arrival
before any placement change is considered; however, any decision regarding Au Pair removal is at AuPairCare’ s sole discret ion and
can be made at any t ime.
64.
Au Pair should not if y t he local AuPairCare represent at ive of any misunderst andings or problems wit h t he Host Family if t hey persist af t er
Au Pair has t ried t o address t hem wit h Host Family. AuPairCare will work wit h bot h Au Pair and Host Family t o at t empt t o resol ve t he
problem bef ore aut horizing a placement change. Au Pair must show a sustained good faith effort to resolve the issues with Host
Family before AuPairCare will approve an Au Pair’ s request for a placement change . If Au Pair does not make a good f ait h and
subst ant ial ef f ort t o resolve t he problems or misunderst andings wit h Host Family, or if Au Pair violat es any t erms of t his Agreement ,
AuPairCare may in it s sole discret ion t erminat e t he Au Pair’ s part icipat ion in t he program and immediat ely repat riat e Au Pair t o his/ her
home count ry at Au Pair’ s expense.
65.
Au Pair underst ands t hat t he nat ure of t he au pair program is one of f lexibilit y and cult ural exchange, and t hat placement changes may
not be request ed in order t o achieve a pref erred work schedule, locat ion, or perks provided by Host Family. Once Au Pair agrees t o
mat ch wit h a Host Family, Au Pair has in ef f ect agreed t o t hat Host Family’ s required schedule, locat ion and benef it s provided by t he
Host Family t o Au Pair. Au Pair agrees t o remain f lexible in order t o cont inually meet Host Family needs as t hey evolve over t he course
of t he program year. Changes in Host Family needs do not constitute grounds for Au Pair to request a placement change.
66.
In t he event Au Pair’ s f irst placement is not successf ul, and AuPairCare det ermines in it s sole j udgment t hat Au Pair shall be placed in a
new f amily, Au Pair agrees to cooperate with AuPairCare during the entire re-matching process, including but not limit ed t o ensuring
t hat pot ent ial new Host Families can easily reach Au Pair by e-mail and phone in a t imely manner t o arrange int erviews. Au Pair is
hereby advised and agrees t hat a replacement Host Family will be provided at t he sole discret ion of AuPairCare and may be dependent
upon current Host Family availabilit y. A replacement Host Family may not be available. In t he event t hat AuPairCare is unable t o
provide a replacement Host Family wit hin 14 days f rom t he end of t he f irst placement , Au Pair’ s part icipat ion in t he program will end
and Au Pair will have t o ret urn home at his/ her personal expense.
67.
If t he Host Family is willing t o house Au Pair unt il she or he is re-mat ched, and AuPairCare, in it s sole discret ion, det ermines t hat under
t he circumst ances it would be reasonable f or Au Pair t o remain in t he home, but t he Au Pair ref uses t o st ay wit h t he f amily, Au Pair will
be required t o pay a $25. 00 per day housing st ipend t o t he part y who houses him/ her, t ypically an AuPairCare f ield st af f member.
68.
If Au Pair leaves t he host f amily home wit hout not ice t o AuPairCare and/ or Host Family and does not cont act AuPairCare wit hin 24
hours f rom depart ure, Au Pair may be subj ect t o dismissal f rom t he program, and Au Pair may be immediat ely repat riat ed t o his/ her
home count ry at Au Pair’ s expense.
69.
In t he event Au Pair does not successf ully complet e t heir f irst year program, and ext ension program, if applicable, Au Pair is responsible
f or his/ her ret urn t ravel expenses.
70.
AuPairCare is not responsible f or any economic damage or loss alleged t o arise f rom loss of or unavailabilit y of a replacement Host
Family.
71.
Au Pair agrees t hat any decision regarding an au pair’ s program st at us, dismissal, or re-placement will be made at t he sole discret ion of
AuPairCare, and said decisions shall be considered f inal.
72.
In t he event of accident or serious illness or medical condit ion t hat , in t he j udgment of AuPairCare, prevent s Au Pair f rom cont inuing
her/ his dut ies, she/ he will end t he program early and ret urn home.
K. Other Terms and Conditions
73.
Au Pair agrees t o leave t he Unit ed St at es wit hin 30 days of t he conclusion of his/ her program. Au Pair underst ands t hat any st ay beyond
t he 30-day grace period is a direct breach of t he Regulat ions of t he Depart ment of St at e, and t hat Au Pair’ s f ut ure abilit y t o t ravel,
work or live in t he Unit ed St at es may be compromised.
74.
Au Pair agrees not t o ent er int o any kind of cont ract ual agreement during t he program year in t he Unit ed St at es, including but not
limit ed t o business, employment , marit al or religious cont ract s.
75.
Au Pair underst ands t hat if he/ she is t erminat ed or volunt arily leaves t he program f or any reason, t hey are not eligible f or t he 30-day
grace period benef it and must depart t he Unit ed St at es immediat ely.
76.
Au Pair consent s and aut horizes AuPairCare t o use Au Pair’ s name, phot ographs, f ile, applicat ion cont ent , video resume (video CV), or
video likeness of Au Pair or any comment s or st at ement s f rom host in mat erials or publicat ions t o promot e t he AuPairCare program.
77.
Au Pair underst ands t hat AuPairCare is not a part y t o any agreement bet ween Au Pair and t he Originat ing Exchange Organizat ion locat ed
in Au Pair’ s home count ry (“ Originat ing Exchange Organizat ion” ). Au Pair acknowledges and agrees t hat t he Originat ing Exchange
Organizat ion is solely responsible t o Au Pair f or inj ury or damage f rom a violat ion of any such agreement . AuPairCare assumes no dut ies
or responsibilit ies f or any act s or omissions of t he Originat ing Exchange Organizat ion.
78.
Au Pair agrees not t o post any Host Family personal inf ormat ion, images or video online or in publicly accessible areas at any t ime,
including bef ore, during or af t er durat ion of of f icial program year, wit hout t he Host Family’ s prior consent .
79.
Au Pair underst ands t hat AuPairCare will make it s best , reasonable and diligent ef f ort s at locat ing and screening all Host Families. Au
Pair agrees t o assume t he risks involved in t he mat ching wit h a Host Famil y, and hereby irrevocably, uncondit ionally, and f ully waives,
releases and f orever discharges AuPairCare, it s subsidiaries, of f icers, employees, and/ or agent s f rom any and all claims relat ed t o
personal and/ or propert y damage, inj ury, loss, delay or expense incurred by Au Pair or any guest , employee or agent , due t o:
Page 5 of 6
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Au Pair’ s Initials__________
(i) event s beyond AuPairCare’ s reasonable cont rol, including wit hout limit at ion act s of God, act s of war or government act ions or
rest rict ions.
(ii) any event s and/ or act s direct ly or indirect ly caused by any int ent ional or negl igent act s or omissions at any t ime, in whole or in part ,
by any Au Pair and/ or Host Family or by any t hird part y, including but not limit ed t o any member, guest , employee or agent of t he Host
Family or ot her persons in t he host count ry, even if AuPairCare’ s negl igence is alleged t o have cont ribut ed t o t he event ,
(iii) risks associat ed wit h f oreign t ravel and living abroad, including but not limit ed t o risks associat ed wit h healt h care services, living
condit ions, sanit at ion condit ions, road and t ransport at ion syst ems, criminal j ust ice syst ems, civil libert y laws, cust oms and values,
(iv) any dif f erences in t he living condit ions and st andards bet ween Au Pair’ s home and home count ry and t he host home and host
count ry, and,
(v) any act or omission of t he Originat ing Exchange Organizat ion.
In t his respect , Au Pair acknowledges t hat neit her Host Family nor Au Pair are an employee or agent of AuPairCare and act ions or
omissions of Au Pair or Host Family are not t o be at t ribut ed in any way t o AuPairCare. Au Pair f ully agrees t o assume all such risks and
agrees t o indemnif y and hold harmless AuPairCare, it s subsidiaries, of f icers, employees and/ or agent s f or any liabilit y or expense,
including court cost s and legal f ees incurred, t hat Au Pair has in any way caused or cont ribut ed t o, whet her direct ly or indirect ly, and
whet her int ent ionally or unint ent ionally.
80.
This Agreement shall be deemed t o have been made in t he St at e of Calif ornia, U. S. , and it s validit y, const ruct ion, breach, perf ormance
and int erpret at ion shall be governed by t he laws of t he St at e of Calif ornia, U. S.
81.
The part ies t o t he Agreement acknowledge and agree t hat any disput e or claim arising out of t his Agreement , including but not l imit ed
t o any result ing or relat ed t ransact ion or t he relat ionship of t he part ies, shall be decided by neut ral, exclusive and binding arbit rat ion in
San Francisco, Calif ornia, U. S bef ore an arbit rat ion provider select ed by AuPairCare, upon t he pet it ion of eit her part y.
In such proceeding, t he part ies may ut ilize subpoenas and have discovery as provided in Calif ornia Code of Civil Procedure Sect ions
1282. 6, 1283 and 1283. 05. The decision of t he arbit rat or shall be f inal and binding and may be enf orced in any court of compet ent
j urisdict ion. Au Pair agrees t hat Calif ornia is a f air and reasonable venue f or resolut ion of any such disput e and it submit s t o j urisdict ion
of t he Court s of t he St at e of Calif ornia because, among ot her reasons, t his agreement was negot iat ed in large part in Calif ornia, and
AuPairCare is domiciled in Calif ornia.
In t he event t hat t he arbit rat ion clause is deemed void or inapplicable, each part y expressly consent s t o and submit s t o t he personal
j urisdict ion of t he f ederal or st at e court (s) of San Francisco Count y, Calif ornia, U. S. In any act ion, including arbit rat ion, brought f or
breach of t his Agreement , t he prevailing part y shall be ent it led t o recover reasonable at t orney’ s f ees and cost s, including but not
limit ed t o t he cost s of arbit rat ion
82.
If t here are any dif f erences bet ween t his Agreement and any ot her program mat erials, t his Agreement shall cont rol. AuPairCare cannot
be legally bound or commit t ed by any person ot her t han a duly aut horized represent at ive. Part ies are required t o f ollow t his Agreement
and cannot vary f rom it s t erms.
83.
An elect ronic or f acsimile signat ure on t his Agreement shall be considered t he same as an original.
ENTIRE AGREEMENT
Please read t he f ollowing st at ement s caref ully. Your signat ure below indicat es you have read and underst ood t hese st at ement s and t hat
you agree t o t hem:
x
x
x
x
x
x
I am capable of reading and underst anding t his Agreement in English
I have had t he opport unit y t o ask quest ions and obt ain advice, t o ensure I underst and t his Agreement in it s ent iret y
I accept t he t erms of t his ent ire Agreement and underst and t hat it is legally binding
I do not rely on any promises, st at ement s or represent at ions t hat are not expressly st at ed in t his Agreement
No alt erat ion of t he t erms of t his Agreement will be valid unless approved by AuPairCare in writ ing
I have ret ained a copy of t his Agreement f or my own records
Au Pair Full Name (Signat ure): ____________________________________________
Au Pair Full Name (Print ): ________________________________________________
Dat e : _______________________________
Mont h/ Day/ Year
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Au Pair’ s Initials__________
2015 Au pair Terms of Contract and Participation for Placement in the AuPairCare
Programme
AuPairCare Europe, represented by Ayusa-Intrax GmbH, facilitates the placement of an au pair stay in the
USA.
Programme Requirements & Rules
The detailed agreement terms of your contractual partner AuPairCare San Francisco are included in your
au pair application. The duration of an au pair stay in the USA is twelve months. This regulation has been
established by the US government authorities.
Your stay can however be extended once by a period of either six, nine or twelve further months. To
obtain this extension you will need to apply to the United States Department of State. As an au pair, you
must stay for a minimum of twelve months.
After having officially finished the programme, you are allowed to stay for a maximum of an additional 30
days. You may use this time for travelling or visiting friends. During this period of 30 days, you are not
allowed to leave and then re-enter the United States.
Neither AuPairCare Europe, represented by Ayusa-Intrax GmbH in Germany, nor AuPairCare San Francisco
can guarantee the placement with an American host family, as host families decide which candidate they
choose to become an au pair in their home.
AuPairCare Programme Fees
Participation in the AuPairCare programme requires the Au Pair to pay a non-refundable programme fee
requested by AuPairCare Europe in the amount of 449 € or reduced 349 € (reduced if the Au Pair has 200
hours of experience with non-related children under 2 years of age and if the Au Pair is willing to care for
them during his/her au pair stay).
The non-refundable fee is due in two instalments as follows:
First Instalment: Once your application process has been completed by AuPairCare Europe, AuPairCare
Europe will request payment of your first instalment of our programme package fee:
First installment of: 90 €
Upon receipt of your first instalment payment, we will send your application to our head office in San
Francisco for a second review. Should the second review be successful, you will be eligible for host
families to interview you.
Second instalment: Once a host family in the US has decided to employ you as their au pair, and you have
agreed to this match, AuPairCare Europe will request payment of your second instalment of our
programme package fee:
Second instalment of: 349 € or reduced 259 € (reduced if the Au Pair has 200 hours of experience with
non-related children under 2 years of age and if au pair is willing to care for them during his/her au pair
stay).
Upon receipt of your second instalment payment we will send you the documents and forms necessary for
your visa application. We will also send you your flight e-ticket receipt in due time before your departure.
Programme Completion
Upon successful completion of the au pair programme you are entitled to a free return flight paid by
AuPairCare San Francisco. You are only entitled to this claim if you have completed the programme
according to the terms and conditions, including the proof of having achieved six credits (or the
equivalent of 60 hours) at an accredited post-secondary college or university.
If these requirements are not fulfilled, if you withdraw voluntarily from the AuPairCare programme before
the contracted duration of twelve months, or if you are dismissed from the programme, then you waive
your right to claim the free return flight. You would then have to pay the cost of your return flight
yourself.
Withdrawal from the AuPairCare Programme before Departure
If you withdraw from the contract after having been successfully matched and placed with a host family,
but before your departure to the USA, AuPairCare Europe is then entitled to claim additional
administrative charges of US$ 300.
If, at the time of withdrawal, a paper flight ticket or e-ticket has already been booked for you, then you
will be held responsible for paying the cancellation fees of the flight ticket. You have the right to prove
that no costs or lesser costs than the above quoted additional administrative charges and possible
cancellation fees have been incurred.
I have read the terms of contract and participation thoroughly and completely.
I acknowledge that I have the ability to ask questions regarding its meaning. I have understood everything
and accept the terms of contract and participation.
Date______________________
Last and First Name (please PRINT): _______________________________________________________
Signature: _________________________________________________________________________________
Emergency contact details:
Please give us the contact details of 2 people in your home country for us to contact in case of an
emergency. Thank you.
Emergency contact –
Person 1
Last name
First name
Cell phone
Work phone
E-Mail
Relationship
Emergency contact –
Person 2