TEMPLATE OF 2021 Host Family - Au Pair of the Year Submission Form

Are you an au pair or host family?

Au PairHost Family

Au Pair's Information*

First NameLast Name

Email

example@example.com

Phone Number*

Please enter a valid phone number.

Your Home Country*

Your Host Family's Information*

First NameLast Name

Your Host Family's Email

example@example.com

Your Host Family's Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Your Arrival Date in the host parents home you are nominating *

Date

Estimated Departure Time

Date

Your Agent Au Pair Support Group Facilitator’s Name

Are you an extension au pair*

Yes, I have extended with same familyYes, I have extended with different familyNo

Why should your host family win this award, what makes your relationship successful? *

How do you and your host family engage in cultural exchange?*

How does your host family make you feel as a family member?*

What is your favorite memory with your host family?*

Host Family information*

First NameLast Name

Email*

example@example.com

Phone Number*

Please enter a valid phone number.

Name of Au Pair who you are nominating*

First NameLast Name

Your Au Pair's Arrival Date in Your Home*

Date

Your Au Pair's Estimated Departure Time

Date

Your Agent Au Pair Support Group Facilitator’s Name

Why should your au pair win this award, what does make your relationship successful?*

How does your au pair contributes to your family dynamics in the household?*

How do you and your au pair engage in cultural exchange?*

What values does your au pair add to in your family?*

PHOTOS

Please share high quality photos to supplement your submission. Should your host family be selected as a Finalist, we will select one photo to display on the Agent Au Pair monthly newspaper and website. (Please be advised that we will not post any photos of your host family publicly without their permission.) Please only upload one photo per file (no collages).

Please complete the photo release form here.

Have you completed and submit your Photo Release Form?*

YesNo

Photo 1*

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Photo 2

function SvgDhtupload2(props) { return /* @__PURE__ */ react.createElement("svg", dhtupload_svg_extends({ width: 54, height: 47, xmlns: "http://www.w3.org/2000/svg" }, props), dhtupload_svg_path || (dhtupload_svg_path = /* @__PURE__ */ react.createElement("path", { d: "M40.213 10.172c1.897.21 3.68.738 5.35 1.58a15.748 15.748 0 0 1 4.374 3.242 15.065 15.065 0 0 1 2.951 4.533c.72 1.704 1.08 3.522 1.08 5.455 0 1.827-.28 3.654-.843 5.48-.562 1.828-1.379 3.47-2.45 4.929A13.39 13.39 0 0 1 46.669 39c-1.599.948-3.452 1.458-5.56 1.528H37.26a1.62 1.62 0 0 1-1.185-.5 1.62 1.62 0 0 1-.501-1.186c0-.457.167-.852.5-1.186.334-.334.73-.5 1.186-.5h3.848c1.44 0 2.75-.37 3.926-1.108a10.851 10.851 0 0 0 3.03-2.846 13.53 13.53 0 0 0 1.95-3.9 14.23 14.23 0 0 0 .686-4.321c0-1.582-.316-3.066-.949-4.454a11.623 11.623 0 0 0-2.582-3.636 12.857 12.857 0 0 0-3.742-2.478 11.054 11.054 0 0 0-4.48-.922l-1.212-.053-.37-1.159c-.878-2.81-2.292-4.998-4.242-6.562-1.95-1.563-4.594-2.345-7.932-2.345-2.108 0-4.005.36-5.692 1.08-1.686.72-3.136 1.722-4.348 3.005-1.212 1.282-2.143 2.81-2.793 4.585-.65 1.774-.975 3.68-.975 5.718h.053l.105 1.581-1.528.264c-1.863.316-3.444 1.317-4.744 3.004-1.3 1.686-1.95 3.584-1.95 5.692 0 2.39.8 4.462 2.398 6.219 1.599 1.757 3.488 2.635 5.666 2.635h4.849c.492 0 .896.167 1.212.5.316.335.474.73.474 1.187 0 .456-.158.852-.474 1.185-.316.334-.72.501-1.212.501h-4.849a10.08 10.08 0 0 1-4.374-.975 11.673 11.673 0 0 1-3.61-2.661 13.173 13.173 0 0 1-2.478-3.9A12.073 12.073 0 0 1 0 28.301c0-2.706.755-5.148 2.266-7.326 1.511-2.178 3.444-3.636 5.798-4.374.14-2.354.658-4.542 1.554-6.562.896-2.02 2.091-3.777 3.584-5.27 1.494-1.494 3.25-2.662 5.27-3.505C20.493.422 22.733 0 25.193 0c1.898 0 3.637.237 5.218.711 1.581.475 3.004 1.151 4.269 2.03a13.518 13.518 0 0 1 3.268 3.215 18.628 18.628 0 0 1 2.266 4.216Zm-11.964 13.44 6.22 6.85c.245.247.368.537.368.87 0 .334-.123.642-.369.923l-.421.263c-.211.246-.484.343-.817.29a1.544 1.544 0 0 1-.87-.448l-3.69-4.11v16.97c0 .492-.166.896-.5 1.212-.334.316-.729.474-1.186.474-.492 0-.896-.158-1.212-.474-.316-.316-.474-.72-.474-1.212V28.25l-3.584 4.005a1.544 1.544 0 0 1-.87.448.959.959 0 0 1-.87-.29l-.42-.264c-.247-.28-.37-.588-.37-.922 0-.334.123-.624.37-.87l6.113-6.746v-.052l.421-.422a.804.804 0 0 1 .396-.29c.158-.053.307-.079.448-.079.175 0 .333.026.474.079.14.053.281.15.422.29l.421.422v.052Z", fill: "none" }))); }

Photo 3

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I consent to the use of my nomination, including photograph(s) by representatives of Agent Aupair, inc., 837Whalley Ave, New Haven, CT 06515 USA and their affiliates, employees, officers and agents to educate the public about our intercultural childcare program. The essay and photos may be included in the following media: the Agent Au Pair website, Agent Au Pair blog, social media posts on Instagram, Facebook, twitter, etc.

Yes, I consent to the use of my nomination, including photos and videosNo, I do not consent to the use of my nomination