HHS Au Pair Program
    Personal Information
Name: First: Middle: Last:
Date of Birth: day  month  year
Gender: Male Female
Nationality:
Ethnicity:
Email:

Skype ID:
The Best Time to Contact You
Cell Phone(national code + area code + no.)
Home Phone/ landline
:
Contact Address:
Street:
City:
State:
Postal Code:
Country:
Emergency Contact Information
Name:
Relation:
Phone:
    Program Information
Program Type: Language Partner Au Pair
Childcare Au Pair
You will be placed in one of the cities below. HHS will seek to place you with the most suitable host family, regardless of location.
Beijing Chongqing Guangzhou Wuhan Changsha Kunming Qingdao Shanghai
Estimated Date of Arrival: day  month  year 
Desired Duration: 3months 6months  12months
    Education Background

University or College:
High School:
Native Language:
Chinese Level:
Other Languages:
    Health Information

Do you have any pre-existing medical conditions or disabilities? Yes  No
If yes, please explain:
Do you have any allergies? Yes  No

If yes, please list the symptoms and treatment

Do you have any physical or medical restrictions? Yes  No
If yes, please list them
Do you take medications or drugs regularly? Yes  No
If yes, Please list medications and conditions being treated.
Have you ever needed treatment, counseling or hospitalization for a psychological or psychiatric condition? Yes  No
If yes, please describe.
Are you presently recovering from an injury or chronic diseases (HIV positive, Hepatitis etc)?
Yes  No
    Additional Information

Please describe yourself

 None-smoker Smoker I will only smoke outside of the house

Have you ever been convicted of a felony or misdemeanor not including traffic violations
Yes  No

If yes,Please explain:

 
Do you have dietary restrictions? Yes No
If so, please list them
Other Requirements

How did you hear about us?

Search Engine Go Abroad.com Media Friends Email BBS eChinacities StudyInChina.com
Other,

Please specify:

Name of the person who referred you to the program if known:

Your HHS program advisor(please select):
None
Arne Eichberg
Gonzalo Moya
Joana Riquet
Thomas Pile
Shanghai Office
Elva wong
Winnie Lu
Other, please specify:

   Dear Family Letter

Please write a “Dear Family” letter. Introduce who you are, where you are from, your hobbies, interests and family. Think about why a family in China can look forward to inviting you into their home.

    Upload your photo
Please make sure your photos are recent and your face is clearly visible.