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onMouseOver="MM_swapImage('buttons_r1_c7','','buttons_r1_c7_f2.gif',1);"><img name="buttons_r1_c7" src="buttons_r1_c7.gif" width="55" height="13" border="0" id="buttons_r1_c7" alt="" /></a></td> <td><img name="buttons_r1_c8" src="buttons_r1_c8.gif" width="39" height="13" border="0" id="buttons_r1_c8" alt="" /></td> <td><a href="contactus.html" onMouseOut="MM_swapImgRestore()" onMouseOver="MM_swapImage('buttons_r1_c9','','buttons_r1_c9_f2.gif',1);"><img name="buttons_r1_c9" src="buttons_r1_c9.gif" width="73" height="13" border="0" id="buttons_r1_c9" alt="" /></a></td> <td><img name="buttons_r1_c10" src="buttons_r1_c10.gif" width="39" height="13" border="0" id="buttons_r1_c10" alt="" /></td> <td><a href="links.html" onMouseOut="MM_swapImgRestore()" onMouseOver="MM_swapImage('buttons_r1_c11','','buttons_r1_c11_f2.gif',1);"><img name="buttons_r1_c11" src="buttons_r1_c11.gif" width="37" height="13" border="0" id="buttons_r1_c11" alt="" /></a></td> <td><img src="spacer.gif" alt="" name="undefined_2" width="1" height="13" border="0" /></td> </tr> </table></td> </tr> </table></td> <td>&nbsp;</td> <td>&nbsp;</td> </tr> <tr> <td colspan="2" rowspan="2" valign="top"><table width="100%" border="0" cellpadding="0" cellspacing="0"> <!--DWLayoutTable--> <tr> <td width="320" height="545" valign="middle"><div align="center"><img src="fees_images.jpg" width="304" height="500"></div></td> </tr> </table></td> <td height="22">&nbsp;</td> <td>&nbsp;</td> <td>&nbsp;</td> <td>&nbsp;</td> <td>&nbsp;</td> </tr> <tr> <td height="523">&nbsp;</td> <td colspan="3" rowspan="2" valign="top"><table width="100%" border="0" cellpadding="0" cellspacing="0"> <!--DWLayoutTable--> <tr> <td width="585" height="84">&nbsp;</td> </tr> <tr> <td height="129" valign="top"><p><strong>Au pairs </strong></p> <p><strong>Registration is free!</strong></p> <p><strong>Are you entitled to work in the UK? <a href="aupair_information_supercare.pdf" target="_blank">Click here to download guidelines</a>. (PDF)</strong></p> <p><strong>What is an Au pair - <a href="what_is_an_aupair.pdf" target="_blank">Click here</a> (pdf)</strong></p> <p><strong>Please complete the registration form below. </strong></p> <p>The fields marked with * are required</p> </td> </tr> <tr> <td height="2552" valign="top"><table width="100%" border="0" cellpadding="0" cellspacing="0"> <!--DWLayoutTable--> <tr> <td width="516" height="2414" valign="top"><form action="http://www.supercareaupairuk.co.uk/form/FormMail.cgi" method="post"> <p> <input type="hidden" name="recipient" value="info@supercareaupairuk.co.uk"> <input type="hidden" name="subject" value="Aupair Application form from website"> <input type="hidden" name="redirect" value="http://www.supercareaupairuk.co.uk/thanks.html"> </p> <p>Last Name &nbsp;<span class="red">*</span><br> <input type="text" size=25 name="lastname"> <br></p><p>First Name &nbsp;<span class="red">*</span><br> <input type="text" size=25 name="firstname"> <br></p><p> Address<br> <textarea name="Address" cols="25" rows="4" id="Address"></textarea><br><br>Home Telephone&nbsp;<span class="red">*</span><br> <input name="Telephone Number" type="text" id="Telephone Number" size="25"> </p> <p>Mobile Phone<br> <input name="Mobile Phone" type="text" id="Mobile Phone" size="25"> </p> <p>Email Address&nbsp;<span class="red">*</span><br> <input name="Email Address" type="text" id="Email Address" size="25"> </p> <p>Skype Address<br> <input name="Skype Address" type="text" id="Text1" size="25"> </p> <p>What is your prefered method of contact?<br> <select name="What is your prefered method of contact?" id="Select3"> <option selected>Please Select</option> <option>Email</option> <option>Phone</option> <option>Skype</option> <option>Don't mind</option> </select> </p> <p>What are your preferred hours of contact?<br> <input type="text" size=25 name="preferredhours"> </p> <p>Date of Birth&nbsp;<span class="red">*</span><br> <input name="Date of Birth" type="text" id="Date of Birth" size="25"> </p> <p>What will be your age when you arrive in the UK?&nbsp;<span class="red">*</span><br> <input name="What will be your age when you arrive in the UK?" type="text" id="What will be your age when you arrive in the UK?" size="10"> </p> <p>Will you have finished high school when you arrive in the UK?&nbsp;<span class="red">*</span><br> <select name="Will you have finished high school when you arrive in the UK" id="Select2"> <option selected>Please Select</option> <option>Yes</option> <option>No</option> </select> </p> <p>Gender&nbsp;<span class="red">*</span><br> <select name="Gender" id="Gender"> <option>Male</option> <option>Female</option> <option>Please Select</option> </select> </p> <p>What is your passport nationality? &nbsp;<span class="red">*</span><br> <input name="what is your passport Nationality and passport number?" type="text" id="what is your passport Nationality and passport number?" size="25"> <p>What is the earliest date you can start?&nbsp;<span class="red">*</span><br> <input name="What is the earliest date you can start" type="text" id="What is the earliest date you can start" size="25"> </p> <p>What is the longest you can stay?&nbsp;<span class="red">*</span><br> <input name="What is the longest you can stay" type="text" id="What is the longest you can stay" size="25"> </p> <p>What age children would you like to work with?<br> <input name="What age children would you like to work with?" type="text" id="What age children would you like to work with?" size="25"> <p>What is your present occupation?<br> <input name="What is your present occupation?" type="text" id="What is your present occupation?" size="25"> </p> <p>What experience do you have with housework?<br> <textarea name="What experience do you have with housework? " cols="25" rows="4" id="What experience do you have with housework? "></textarea> </p> <p>What experience do you have working with children?<br> <textarea name="What experience do you have working with children" cols="25" rows="4" id="What experience do you have working with children"></textarea> </p> <p>Are you prepared to work with a single parent?&nbsp;<span class="red">*</span><br> <select name="Are you prepared to work with a single parent" id="Are you prepared to work with a single parent"> <option>Please Select</option> <option>Yes</option> <option>No</option> </select> </p> <p>Can you work with handicapped children?<br> <select name="Can you work with handicapped children? " id="Can you work with handicapped children? "> <option>Please Select</option> <option>Yes</option> <option>No</option> </select> </p> <p>Do you have any health problems?&nbsp;<span class="red">*</span><br> <select name="Do you have any health problems?" id="Do you have any health problems?"> <option>Please Select</option> <option>Yes</option> <option>No</option> </select> </p> <p>What is the nature of the health problem (if applicable)<br> <textarea name="What is the nature of the problem" cols="25" rows="4" id="What is the nature of the problem"></textarea> </p> <p>Are you a vegetarian?<br> <select name="Are you a vegetarian?" id="Are you a vegetarian?"> <option>Please Select</option> <option>Yes</option> <option>No</option> </select> </p> <p>Do you smoke?&nbsp;<span class="red">*</span><br> <select name="Do you smoke?" id="Do you smoke?"> <option>Please Select</option> <option>Yes</option> <option>No</option> </select> </p> <p>What religion are you?<br> <input type="text" size=25 name="Religion"> </p> <p>Do you drive?&nbsp;<span class="red">*</span><br> <select name="Do you drive?" id="Do you drive?"> <option>Please Select</option> <option>yes</option> <option>No</option> </select> </p> <p>Have you got a driving licence?<br> <select name="Have you got a driving licence?" id="Have you got a driving licence?"> <option>Please Select</option> <option>Yes</option> <option>No</option> </select> </p><p>Are you planning to drive in the UK?<br> <select name="Are you planning to drive in the UK?" id="Are you planning to drive in the UK?"> <option>Please Select</option> <option>Yes</option> <option>No</option> </select> </p> <p>Which of these locations would you like to live in?&nbsp;<span class="red">*</span><br> <select name="Which of these would you like to live in?" id="Which of these would you like to live in?"> <option selected>Please Select</option> <option>Village / Countryside</option> <option>Town</option> <option>City</option> <option>Don't mind</option> </select> </p> <p>Do you have a criminal record?&nbsp;<span class="red">*</span><br> <select name="Do you have a criminal record?" id="Do you have a criminal record?"> <option>Please Select</option> <option>Yes</option> <option>No</option> </select> </p> <p>If yes, what is the nature of the offence and how long ago was this offence committed?&nbsp;<BR> <textarea name="'What is the nature of the offence and how long ago was this offence committed?" cols="25" rows="4" id="'What is the nature of the offence and how long ago was this offence committed?"></textarea> </p> <p>Do you like pets?<br> <select name="Do you like pets?" id="Do you like pets?"> <option>Please Select</option> <option>Yes</option> <option>No</option> </select> </p> <p>Tell us about your family<br> <textarea name="Tell us about your family" cols="25" rows="4" id="Tell us about your family"></textarea> </p> <p>What are your hobbies and interests?<br> <textarea name="What are your hobbies and interests?" cols="25" rows="4" id="What are your hobbies and interests?"></textarea> </p> <p>Have you ever taken any courses in childcare or health?<br> <textarea name="Have you ever taken any courses in childcare or health? " cols="25" rows="4" id="Have you ever taken any courses in childcare or health? "></textarea> </p> <p>How good is your English?&nbsp;<span class="red">*</span><br> <select name="How good is your English?" id="Select1"> <option>Please Select</option> <option>Basic</option> <option>Intermediate</option> <option>Fluent</option> </select> </p> <p>What is your main reason for becoming an Au pair?<br> <textarea name="What is your main reason for becoming an Au pair" cols="25" rows="4" id="What is your main reason for becoming an Au pair"></textarea> </p> <p>Where did you hear of us?&nbsp;<span class="red">*</span><br> <select name="Where did you hear of us?" id="Where did you hear of us?"> <option selected>Please Select</option> <option>Yell.com</option> <option>Google</option> <option>Word of mouth</option> <option>ICOC member</option> <option>Other</option> </select> </p> <p> <strong>Declaration:</strong> the above information is true to the best of my knowledge and true at the time of writing. (Please tick the box if you agree)&nbsp;<span class="red">*</span> <input id="chkBoxTerms" name="Agree to terms ?" type="checkbox" /> </p> <p>Please send us through your reference forms (TWO needed) and medical form as soon as possible to info@supercareaupairuk.co.uk Your registration will be considered incomplete as long as we have not received them.</p> <a href="ReferenceForm.doc" target="_blank">Reference forms</a>, <a href="AuPairMedicalForm.doc" target="_blank">Medical form</a> <p><br/> <br/> <input value="Send" type="submit"> <input value="Clear Form" type=reset> </p> </form></td> <td width="69">&nbsp;</td> </tr> </table></td> </tr> <tr> <td height="8"></td> </tr> <!--DWLayoutTable--> </table></td> <td>&nbsp;</td> </tr> <tr> <td height="2250">&nbsp;</td> <td>&nbsp;</td> <td>&nbsp;</td> <td>&nbsp;</td> </tr> <tr> <td height="12"></td> <td></td> <td></td> <td></td> <td></td> <td></td> <td></td> </tr> </table></td> </tr> <tr> <td height="15"></td> </tr> </table> </div></body> </html>