Contact
Your Name*
Email Address*
Current Address
Home Phone
Cell Phone
Country (you are currently in) Select One Afghanistan Aland Islands Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Barbados Bangladesh Belarus Belgium Belize Benin Bermuda Bhutan Botswana Bolivia Bosnia and Herzegovina Bouvet Island Brazil British Indian Ocean Territory Brunei Darussalam Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Congo, Democratic Republic Cook Islands Costa Rica Cote D'Ivoire (Ivory Coast) Croatia (Hrvatska) Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands (Malvinas) Faroe Islands Fiji Finland France France, Metropolitan French Guiana French Polynesia French Southern Territories F.Y.R.O.M. (Macedonia) Gabon Gambia Georgia Germany Ghana Gibraltar Great Britain (UK) Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Heard and McDonald Islands Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Israel Isle of Man Italy Jersey Jamaica Japan Jordan Kazakhstan Kenya Kiribati Korea (North) Korea (South) Kuwait Kyrgyzstan Laos Latvia Lebanon Liechtenstein Liberia Libya Lesotho Lithuania Luxembourg Macau Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Monaco Moldova Morocco Mongolia Montserrat Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Antilles Neutral Zone New Caledonia New Zealand (Aotearoa) Nicaragua Niger Nigeria Niue Norfolk Island Northern Mariana Islands Norway Oman Pakistan Palau Palestinian Territory Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Reunion Romania Russian Federation Rwanda S. Georgia and S. Sandwich Isls. Saint Kitts and Nevis Saint Lucia Saint Vincent & the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Seychelles Sierra Leone Singapore Slovenia Slovak Republic Solomon Islands Somalia South Africa Spain Sri Lanka St. Helena St. Pierre and Miquelon Sudan Suriname Svalbard & Jan Mayen Islands Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States US Minor Outlying Islands Uruguay Uzbekistan Vanuatu Vatican City State (Holy See) Venezuela Viet Nam Virgin Islands (British) Virgin Islands (U.S.) Wallis and Futuna Islands Western Sahara Yemen Yugoslavia Zambia Zimbabwe
Date of Birth 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 January February March April May June July August September October November December 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000
Country of birth Select One Afghanistan Aland Islands Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Barbados Bangladesh Belarus Belgium Belize Benin Bermuda Bhutan Botswana Bolivia Bosnia and Herzegovina Bouvet Island Brazil British Indian Ocean Territory Brunei Darussalam Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Congo, Democratic Republic Cook Islands Costa Rica Cote D'Ivoire (Ivory Coast) Croatia (Hrvatska) Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands (Malvinas) Faroe Islands Fiji Finland France France, Metropolitan French Guiana French Polynesia French Southern Territories F.Y.R.O.M. (Macedonia) Gabon Gambia Georgia Germany Ghana Gibraltar Great Britain (UK) Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Heard and McDonald Islands Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Israel Isle of Man Italy Jersey Jamaica Japan Jordan Kazakhstan Kenya Kiribati Korea (North) Korea (South) Kuwait Kyrgyzstan Laos Latvia Lebanon Liechtenstein Liberia Libya Lesotho Lithuania Luxembourg Macau Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Monaco Moldova Morocco Mongolia Montserrat Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Antilles Neutral Zone New Caledonia New Zealand (Aotearoa) Nicaragua Niger Nigeria Niue Norfolk Island Northern Mariana Islands Norway Oman Pakistan Palau Palestinian Territory Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Reunion Romania Russian Federation Rwanda S. Georgia and S. Sandwich Isls. Saint Kitts and Nevis Saint Lucia Saint Vincent & the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Seychelles Sierra Leone Singapore Slovenia Slovak Republic Solomon Islands Somalia South Africa Spain Sri Lanka St. Helena St. Pierre and Miquelon Sudan Suriname Svalbard & Jan Mayen Islands Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States US Minor Outlying Islands Uruguay Uzbekistan Vanuatu Vatican City State (Holy See) Venezuela Viet Nam Virgin Islands (British) Virgin Islands (U.S.) Wallis and Futuna Islands Western Sahara Yemen Yugoslavia Zambia Zimbabwe
Nationality
Age
Height
Weight
Religion
Marital status
Number of own children
Ages of children
Do you have any brothers or sisters? Select One Yes No
Do you speak fluent English? Select One Yes No
Do you speak other languages? If so, what other languages do you speak?
How did you hear about us?
Do you have any health conditions that could prevent you from doing essential duties in your job?
Are you on a special diet?
Do you have any allergies? If yes, what?
Do you smoke? Select One Yes No
Do you drink? Select One Yes No
Are you able to provide us with a record of health if asked? Select One Yes No
Do you consider yourself physically fit? Select One Yes No
Can you play a musical instrument? if so, what instrument(s)?
Can you swim? Select One Yes No
Can you ride a bike? Select One Yes No
Do you like to read? Select One Yes No
What are your interests or hobbies?
Do you have a valid driver’s license? Select One Yes No
Do you have an international license? Select One Yes No
Are you willing to learn how to drive if you are unable too? Select One Yes No
Have you ever been convicted of a criminal offense or been arrested?
Do you have many friends? Select One Yes No
If you are away from your family, how long has it been since you have seen them?
Are you currently in a working contract? If yes, which country?
When does the contract expire?
Is Canada your preferred location? Select One Yes No
What date are you able to start work? 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 January February March April May June July August September October November December 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020
College or University attended
Year graduated
Subject of study
Diploma achieved
Additional education
Child related training
Do you have 6 months to 1 year or more of any caregiver training in a classroom setting? Select One Yes No
Do you have CPR, First aid or Other training?
What kind of a student did you consider yourself as?
What do you feel is more important: (1) Learning from what we are taught in school, (2) Learning from hands on training , (3) Learning from repetition
Do you prefer being “told” how to do it rather than figuring it out on your own?
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Employment History - Please list your last 2 jobs beginning with the most recent. Please be as specific as possible.
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Employer’s name
Position
Start of employment 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 January February March April May June July August September October November December 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
Finish Date 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 January February March April May June July August September October November December 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020
Number of children
Ages of children
Eldercare
Responsibilities
Reason for leaving
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Employer’s name
Position
Start of employment 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 January February March April May June July August September October November December 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
Finish Date 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 January February March April May June July August September October November December 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020
Number of children
Ages of children
Eldercare
Responsibilities
Reason for leaving
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How much notice does your current employer need for you leaving?
Can we contact your current employer for a reference? Does he/she speak English?
Will you have enough money for the airfare to Canada? Select One Yes No
Please describe in detail your childcare experience (ages of children, length of care, etc...)
Total number of years experienced as a nanny
Are you willing or able to care for special needs children? Select One Yes No
Do you have a preference? (Babies, 2-5 yrs, over 5 yrs, etc…)
Could you handle more than 2 children? Select One Yes No
Mixed ages? Select One Yes No
How many children are you willing to take care of?
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Do you have paid experience looking after the elderly? Select One Yes No
If yes, how many months/years?
Have you worked as a caregiver for the elderly within the last 3 years? Select One Yes No
Please describe your experience with the age and conditions of the person. Also, duties or any information you feel may be helpful to us
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Are you not willing to do any of the tasks listed below? If so, Explain
Full housekeeping
Light housekeeping (only)
Organize house
Organize clothing
Do laundry
Run errands
Prepare children’s meals
Prepare meals for the family
Walk children to school
Pet care
Gardening
Sewing
Ironing
Maintain lists such as shopping
Maintain a logbook if required by the employer
Do you enjoy cooking? Select One Yes No
How would you rate your cooking? Select One Average Good Exceptional
If you can cook, what types of meals?
What is your favorite food(s)?
Do you have any objections to pet’s in the home? If yes, please specify
Do you have any friends or relatives currently working or residing in Canada? If yes, (optional) give names, locations and phone numbers
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Please take a few moments to explain to us and your potential employer why you would make a good caregiver
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Agreement and Authorization
I hereby give full permission to Americanadian Inc. to do a thorough reference check which may include information on my education, past working experience, character, police record and driving record.
I understand that Americanadian Inc. is acting solely as a referral agent and at no time will be the employer. I am under no obligation to accept a job from anyone that Americanadian Inc. refers me to.
I hereby relinquish all possible liability or claims from Americanadian Inc. At no time will Americanadian Inc. be responsible for any damage, injury or loss resulting from employment from an Americanadian Inc. referral.
I agree to keep all information about the host family confidential in respecting the family’s privacy.
I acknowledge that my registration will not guarantee me a suitable placement with a host family, and Americanadian Inc. will not be responsible if the employment is unsuccessful. I understand that Americanadian Inc. is not required to reimburse me for any expenses that I may incur should I voluntarily or involuntarily terminate my employment. I am aware that there is a contractual agreement between Americanadian Inc. and my host family, and thus I may not contact the family or arrive at their home until all conditions are fulfilled as set in the agreement between the agency and the host family. I understand that severe penalties and legal costs could arise for both the family and me if this condition is not satisfied.
I have read and understand all of the preceding statements in this contract and confirm my agreement by clicking the submit form button .
