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

2021 Host Family - Au Pair of the Year Submission Form

Please complete this form to nominate your Host Family or your Au Pair for Agent Au Pair’s “Host Family and Au Pair of the Year" Award!
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 *

MonthDayYear
Date
Estimated Departure Time

MonthDayYear
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*

MonthDayYear
Date
Your Au Pair's Estimated Departure Time

MonthDayYear
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*

Cancelof
Photo 2

Cancelof
Photo 3

Cancelof
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
Should be Empty: