HOST FAMILY PROFILE

151 East 6100 South, Suite 200

Pete & Elizabeth Bruinsma
Murray, Utah 84107
315 Paris SE
801.255.7722 801.255.7782 fax

Grand Rapids, MI www.GoAuPair.com

My Child Care

1. My Needs
Select the type(s) of child care you have used in the past: Au Pair
Why are you considering Au Pair child care? Our contract has expired and our Au Pair is going home.
Describe a typical day with your family: A typical day is predictable, AuPair works Monday-Friday 8-5 while Pete
(How your Au Pair will work with your daily schedule) and Liz work.
How many hours of child care do you need:
Daily: 9
Weekly: 45
What skills will your Au Pair need to perform their child care
responsibilities?

Driving: Yes

If Yes, answer all applicable questions:

Describe how often your Au Pair will drive and the road and traffic Driving is great, but its easy to walk to a lot of activities with Jake.
conditions they can expect:

Swimming: No

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 If Yes, answer all applicable questions:
Describe how often your Au Pair will swim and the swimming You dont need to swim, but we have a pool/gym membership in case you
environment such as a public pool or lake: would like to swim.
OPTIONAL: Cooking No

If Yes, answer all applicable questions:

Describe the type of meals your Au Pair will make and how often they Liz loves to cook. Au Pair is welcome to cook also, but not required for the
will cook: family's needs. We like trying new foods.
OPTIONAL: Describe other skills or qualifications your Au Pair needs to
perform child care responsibilities:

What’s most important to you when it comes to child care? Caring; looking out for the child and the family.
OPTIONAL: When would you like your Au Pair to arrive? Month: 2
Year: 2020

2. Children

First Name Last Name Gender Age

Jacob Bruinsma Male 2

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 Jacob Bruinsma
1. Identity
OPTIONAL: Nickname:
Gender: Male
Birthday: 9/5/2017

2. Special Care
Does this child require special care? No

If you answered Yes, complete this section. If No, continue to next section:
Select the type(s) of special care:
Describe the extent of care needed and how it may impact your Au Pair:

3. Additional Information
OPTIONAL: Select your child's interest and hobbies: Art; Baseball/Softball; Dance; Gymnastics; Jogging/Running; Literature;
Music-Listening; Music-Singing; Pets; Quilting; Reading; Socializing with
Friends; Sports; Swimming
OPTIONAL: Is your child adopted or a multiple birth:
OPTIONAL: Describe your child’s personality: Happy and content. He loves to sleep.

My Au Pair

1. Requirements and Preferences

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 OPTIONAL: Au Pair’s Language(s):
We want the following languages... Spanish
OPTIONAL: This is a: Requirement
• OPTIONAL: Please explain: We would like to continue Jacob's exposure to Spanish and we would like for
you to speak with Jacob primarily in Spanish.

OPTIONAL: Au Pair’s Nationality:

We want the following nationalities... Argentinean;Brazilian;Colombian;Costa
Rican;Ecuadorian;Mexican;Panamanian;Peruvian;Salvadorian;Spanish;South
/Central America and Caribbean
OPTIONAL: This is a: Preference
• OPTIONAL: Please explain: Latina preferred

OPTIONAL: Au Pair’s Age:

We want an Au Pair who is in the age range of… 20-30

OPTIONAL: This is a: Preference

OPTIONAL: Please explain: A younger adult seems fitting for this kind of task and how we understand
things.

OPTIONAL: Au Pair’s Personality:

OPTIONAL: What lifestyle / personality traits would you like your Au Pair to We are amiable, and would love someone to talk to at dinner and join us for
have? some activities. We also need someone who can be independent. We
appreciate your company, and happy to give you space and alone time.
OPTIONAL: Do you have any other preferences or restrictions for your Au No, but a wide range of dietary options are available. Liz is vegan and Pete is
Pair? not.

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 OPTIONAL: Au Pair’s Gender: Female

2. Family

What is the relationship status of the Host Parents? Married

Do you have pet(s)? Yes

If Yes, answer all applicable questions:

What type of pet(s) do you have? Dogs
Describe your pet(s) / which family member is responsible for its care: 11 Year old chocolate lab, very loving. Not as fast as he used to be. Pete and
Liz take care of him.
How soon after arriving will your Au Pair need to learn to drive? After the first month
How will you help your Au Pair adjust to driving in the U.S. / your area? We dont anticipate driving will be a big part of the AuPair's duties or
expectations.
Describe the ideal relationship between your Au Pair and your Loving, nurturing, talking, walking.
child(ren):

What nationality(ies) is your family? Dutch

What is the primary language spoken in the home? English

Besides English, what languages are spoken in your home? No other languages
OPTIONAL: Briefly describe your neighborhood for your potential Au We live in an historic neighborhood with lots of tall trees and homes from the
Pair: Victorian revivalist era. We are within a couple of blocks of 2 parks, childrens
museum, transportation, medical and education. Very safe location, lots of
walking and biking.
OPTIONAL: How close are you to churches, shopping, entertainment, Walking distance to churches, shopping, entertainment and more. For what is
etc.? not in reach there is a bus stop at end of street. Minimum/base charge to take
an Uber to anything Downtown.

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 What type(s) of public transportation are available in your local area? Bus;Train;Taxi / Ride Share
Will your Au Pair have access to a car for personal use? Limited access

How do you plan to contribute to your Au Pair’s cultural experiences We really enjoyed finding out what Alejandra & Valeria liked to do and found
and success in the United States? activities to tie in to their preferences. We'd love to take you to sandy Lake
Michigan beach, go fishing, go to festivals, breweries. We drove both to
Chicago 2x.

3. Family

What religious affiliation(s) are in the home? Christian

OPTIONAL: How might the religion(s) practiced in your home impact your Au We do not expect you to be religious or participate with us in any way.
Pair?

Does your family have any dietary restrictions? No restrictions

How does your family like to spend leisure time? Any favorite City life, local recreation, exercise, go to the beach.
activities?

OPTIONAL: What race(s) is your family? White

OPTIONAL: What is the sexual orientation of the Host Parents? Straight / Heterosexual

OPTIONAL: How important is it to have your home clean and tidy? 9

(1-Very Causal, 10-Meticulous)
• OPTIONAL: Explain your ranking: Cleanliness is important.

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 Do you have frequent overnight guests in your home? No
• If Yes, explain who, the relation, and the frequency:

Do you have any guests (adults and children) that visit regularly or for No
extended periods of time? (two weeks or more full time)
• If Yes, please explain:

Does anyone in your home consume alcoholic beverages? Sometimes / socially

• If more frequently than never, please explain: Fans of beer, quite common for the area.

Does anyone in the home smoke? No

• If Yes, does it happen in the home?
• If Yes, explain who, the frequency and where they smoke:

OPTIONAL: Are all members of your family in good health? Yes

OPTIONAL: If No, please explain:

Family

1. Contact Information
Billing Address:

Street City State Zip Code Home Phone

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 315 Paris SE Grand Rapids MI 49503 (616) 706-2736

Mailing Address:

Street City State Zip Code

315 Paris SE Grand Rapids MI 49503

Will your Au Pair be staying at a different residence or location for an No

extended period of time?

If Yes, complete the next question and address fields:

Describe the residence, frequency, and duration of your Au Pair’s stay:
Street City State Zip Code

2. Au Pair
What backup child care do you have for unexpected lapses? Neighborhood network, community association.
Who is responsible for child care when the Au Pair is off-duty? Parents.

Are there children who are not a family member that your Au Pair will No
regularly interact with?
• If Yes, who and in what capacity?

All Au Pairs must attend classes taught through an accredited Over 15 institutions of higher education exist close by. Hosts are well
post-secondary academic institution (college/university). connected in the art, music, and nonprofit world, and will take pleasure in
finding a good fit for the student.
Which airport do you prefer for your Au Pair's arrival? MI, Grand Rapids (GRR)

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 Which airport is your second choice for airport arrival? Detroit

OPTIONAL: Provide your video/web conferencing contact information:

OPTIONAL: Provide your family's social media URLs:
Do you have a private bedroom for your Au Pair? Yes
(A room the family won't need to access to at anytime.)
• If the bedroom is not private or you don't have a room, explain: Bedroom and bathroom have their own staircase and are somewhat separate.

Has anyone in your home ever been arrested? No

• If Yes, please explain:

Has anyone in your home ever been convicted of an offense other No

than a minor traffic violation?
• If Yes, please explain:

Has your family had any incidents of domestic violence that were No
reported to the police or social service agencies?
• If Yes, please explain:

Does anyone in your home take recreational drugs, Illegal drugs or Never
legal drugs outside of prescribed use?
• If more frequently than never, please explain:

3. Parent Information

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 Full Name Relation Primary Contact Lives in Home Host Parent
Elizabeth Bruinsma Mom Yes Yes
Pete Bruinsma Dad Yes Yes

Elizabeth Bruinsma Host Parent: Yes

1. Identity
OPTIONAL: Preferred name to be called by:
What is your relationship to the children? Mom
Do you live full-time in the home? Yes
Do you need a username/password to manage your account in the Go No
Au Pair Community?

2. Contact Information
Email: elizabethbruinsma@gmail.com
OPTIONAL: 2nd email:
Mobile: 616-706-2736
OPTIONAL: Preferred method of contact: Email
OPTIONAL: Best time(s) of day to contact you:
Will you be the primary contact for day-to-day matters?

3. Employment and Travel

Are you currently employed? Yes

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 If Yes, complete section below:
Approximately when do you leave home for work and return home from Usually work from home Mon-Fri 7:30-4:30
work? (If you work from home specify your start/finish time):
Describe the frequency and duration of any personal or work-related A few days once/month by myself (Pete stays)
overnight travel:
Occupation: Architecture
Company name: tbd
OPTIONAL: Company address: tbd
OPTIONAL: Company phone: tbd
OPTIONAL: Company email:

4. Additional Information
Are you a U.S. citizen or permanent legal resident? Yes
• If “No,” please explain:

Are you fluent in spoken English? Yes

• If “No,” please explain:

Do you require special care? No

• If “Yes,” please explain:

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 Pete Bruinsma Host Parent: Yes
1. Identity
OPTIONAL: Preferred name to be called by:
What is your relationship to the children? Dad
Do you live full-time in the home? Yes
Do you need a username/password to manage your account in the Go Yes
Au Pair Community?

2. Contact Information
Email: petebr@grar.com
OPTIONAL: 2nd email:
Mobile: 6162935731
OPTIONAL: Preferred method of contact: Email
OPTIONAL: Best time(s) of day to contact you:
Will you be the primary contact for day-to-day matters?

3. Employment and Travel

Are you currently employed? Yes

If Yes, complete section below:

Approximately when do you leave home for work and return home from Appointment based; often coming and going. Home almost all mornings.
work? (If you work from home specify your start/finish time):
Describe the frequency and duration of any personal or work-related Rare
overnight travel:
Occupation: Sales and Related - Real Estate

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 Company name: Grand River Realty
OPTIONAL: Company address: 330 Fuller Ave NE Grand Rapids MI 49503
OPTIONAL: Company phone: 616-389-0881
OPTIONAL: Company email:

4. Additional Information
Are you a U.S. citizen or permanent legal resident? Yes
• If “No,” please explain:

Are you fluent in spoken English? Yes

• If “No,” please explain:

Do you require special care? No

• If “Yes,” please explain:

Photos

Family

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 Caption: family

Caption: au pair Vale

Caption: friends at the grand rapids museum

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 Caption: AuPair event, Dia de los muertos

Caption: August 2019 - Oregon

Caption: jake and pete

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 Caption: liz and jacob

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 Caption: We spend a lot of time on the front porch

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 Caption: AuPair event, Dia de los muertos

Family Home
Caption: This is our house.

Other
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 Caption: jake at hoover dam

Caption: jake at Cubs game in Chicago

Caption: Pete, Liz, Jake, and Mayor Rosalynn Bliss at Brewery Vivant.

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 Caption: Vale, Liz and friend Ben brewing beer in garage

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 Caption: Letter from 2018 Au Pair Valeria Vaca Lopez

Caption: Lake Michigan, 30 minute drive

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 Caption: We spend a lot of time on the front porch

Caption: New years eve celebration

Caption: making snow angels in January

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 Letter

Hello,

We are very glad to have you consider our family for 2020! We look forward to having a friendship with you as well as a professional relationship.

Elizabeth and I very much enjoy living in downtown Grand Rapids Michigan, and we hope you do too. This is a safe city with friendly people. This is not a huge
city, but it is mid-sized. We are a 3 hour Amtrak train ride or car ride away from Chicago, a 30 minute drive from Lake Michigan. We enjoy eating, going out,
nature, water, sand, and being active. Liz likes to read, cook, sew and she is nice to talk to. I like listening to music, going to concerts, playing sports, and taking
Jake swimming.

Jacob (Jake) is a happy boy, and we know we got lucky with him when we hear stories of other babies. He is a little mischievous, full of energy and love. He also
loves to sleep. Since his first day home he slept through the night in his own bed and own room. He eats a wide variety of foods. He is able to entertain himself but
enjoys attention. Jake knows when he is being funny, which is funny for us. He needs somebody to teach him and challenge him, and have fun with him.

We have a big house, your bedroom and bathroom will be in the back of the home down a hallway, while our bedroom and Jake's bedroom are in the front. You
have a little extra separation and privacy with this arrangement.

This year our winter is projected to be mild. Usually Spring comes quickly in April, Michigan summers are the very best! Fall season is great with lots of color. You
will find lots to do with hiking, camping, water, a lot of people come from Chicago to vacation in Michigan. Grand Rapids has a few places to dance and you'll find a
lot of festivals and events to attend.

Finally, we've found that there are several other Au Pairs in Grand Rapids Michigan that come from South and Central America. It seems that the group has
regular meet-ups that might help you feel more at home while you are away. We've had some events at our home for the group, but they often go out for coffee or
nightlife.

Here is a video with Jake and Val: https://youtu.be/1sj7JduWaJM

Here is a video with Jake and Ale: [to be added]

Thanks for considering us!

Sincerely,

Pete

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Tab Status

Au Pair Needs: Approved

Children: Approved
Culture and Relationships: Approved
Family: Approved
Parents: Approved
Photos: Approved
Letter: Approved
Au Pair Duties: Approved
Au Pair Benefits: Approved

Reviewed Host Family Profile

AP Initials: {{*Int_es_:signer1:initials}}

HF Initials: {{*Int_es_:signer2:initials}}

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The following pages below could be incomplete.

If you would like to know an answer to any of the incomplete questions

we recommend that you ask the Host Family directly.

The following pages below could be filled out at any time during the
matching process.

A complete version of these pages will be sent if the family chooses to

extend an offer.

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 151 East 6100 South, Suite 200
CHILD CARE SERVICES Murray, Utah 84107
801.255.7722 801.255.7782 fax
AGREEMENT www.GoAuPair.com

This Child Care Services Agreement is between __Bruinsma, Pete & Elizabeth____________________ (“Host

Family”) with primary residence at 315 Paris SE Grand Rapids, MI 49503

and (“Au Pair”) from the country of (collectively “Parties” and individually “Party”) for a cultural experience and child care
services sponsored by Go Au Pair Operations, LLC (“Go Au Pair”) through the US Department of State (“DOS”) Au Pair
Visitor Program (“Au Pair Program”). Each Party warrants they have read and understand the DOS’ Au Pair Program goal to
increase mutual understanding between the people of the United States and other countries through an educational and
cultural exchange so the Au Pair can return home to share their experiences with others in their home country.

This Child Care Services Agreement and the below items (collectively the “Child Care Agreement”) document the agreement
of the Parties’ responsibilities, work schedule, and living arrangements to be followed during the term of the Au Pair Program:
1. United States Department of State (“DOS”) Regulations on the Au Pair Visitor Exchange Program in Title 22 CFR 62
(“DOS Regulations”), specifically 22 CFR 62.31 – Defines the regulations the Au Pair and Host Family must follow to
participate in the Au Pair Program.
2. Au Pair and Host Family Orientation (“Orientation”) is to be completed within the first two weeks of the Au Pair’s arrival
and is conducted by the Go Au Pair Local Area Representative (“LAR”) with the Parties and all adults living in the home.
The Orientation will be signed by the Host Family, Au Pair, and any other adult living in the home.
3. Go Au Pair Mediation Policy (“Mediation Policy”) - This policy describes the steps to be followed if issues arise during the
Au Pair Program.
4. Hours & Wages Log - The Au Pair will record the hours worked and wages paid. When accurate, the Host Family and
Au Pair will initial the log.
5. Medical Consent Form - If the Host Family requests the Au Pair to perform any Layman Treatment and the Au Pair
accepts, this form must be signed by both the Host Family and Au Pair.

This Child Care Agreement is effective on the date both Party sign it and continues to the end date on the Au Pair’s Form DS-
2019 or until the Au Pair leaves the United States, whichever is later (“Placement End Date”). The Parties acknowledge: the
Au Pair is not an employee, independent contractor, or agent of Go Au Pair; the Au Pair is an employee of the Host Family;
the Host Family is solely responsible to supervise all Child Care Services performed by the Au Pair. (Reg. 62.2; 62.31.e.5;
62.31.h.6)

1. Work Schedule
The work schedule (“Work Schedule”) on the next page describes the activities, duties, and hours each day in the week. The
work schedule may be periodically modified by mutual agreement. The Parties agree the Au Pair will not work more than 10
hours a day or 45 hours a week (30 hours per week for an EduCare Au Pair) and the Au Pair will receive a minimum of one
and one half days off a week in addition to one complete weekend off a month. (Reg. 62.31.c.2; 62.31.j.2-3)

2. Duties and Responsibilities

2.1 The Au Pair’s duties and responsibilities for child care services (“Child Care Services”) are documented by the Host
Family on the page after the work schedule. (Reg. 62.31.e.5; 62.31.h.6) Some examples of responsibilities which do NOT
comply with DOS guidelines include:
• Heavy housework – cleaning/dusting entire house, gardening, mowing, painting, etc
• Caring for pets, elderly or handicapped adults
• Running the entire household when Host Family is regularly absent
• Caring of child under the age of 3 months without a Host Family parent or other responsible adult present (Reg.
62.31.e.2 )
2.2 The DOS Regulations have three unique requirements that may exist in this placement with the Host Family. The
Host Family has identified on the table in this section whether any of the following are present in the home:
• Infant Experience: If the Host Family has children under the age of two, the Host Family and Au Pair have
confirmed the Au Pair has at least 200 hours of documented infant child care experience. (Reg. 62.31.e.3)
• Special Care Child(ren): The Host Family must identify all children requiring Special Care (see definition in Section
15.1) and personally review and confirm to their satisfaction that the Au Pair has the necessary experience, skills,
and training to care for all such children. (Reg. 62.31.e.4)
• EduCare: If Au Pair is with the EduCare program, the Host Family has full time arrangements in place for
supervising the pre-school children. (Reg. 62.31.e.3 )

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 151 East 6100 South, Suite 200
CHILD CARE SERVICES Murray, Utah 84107
801.255.7722 801.255.7782 fax
AGREEMENT www.GoAuPair.com

Section 1 - Work Schedule

Schedule Hours Description of Duties & Activities Total Hours

8am-5pm Watch child, light housework 9

Monday

8am-5pm Watch child, light housework 9

Tuesday

8am-5pm Watch child, light housework 9

Wednesday

8am-5pm Watch child, light housework 9

Thursday

8am-5pm Watch child, light housework 9

Friday

None None 0

Saturday

None None 0

Sunday

Total Weekly Hours = 45

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 151 East 6100 South, Suite 200
CHILD CARE SERVICES Murray, Utah 84107
801.255.7722 801.255.7782 fax
AGREEMENT www.GoAuPair.com

Section 2.3 – Duties and Responsibilities

Child Care Duties Yes/No Comments

Playing with child(ren) Yes
Reading & enrichment Yes
Helping with school
No
homework

Tutoring Foreign Language No

These are preferred a few days a week weather permitting, but not necessarily required
Walks & Exercise Yes
every day.
Driving / transport – to / trom
No
school
Driving / transport – to / from Activities are mostly walking, but driving is an option too. We are close to the zoo,
Yes
activities childrens museum, parks and playgroups.
Preparing children meals Yes
Cleaning up after child(ren)
Yes
meals
Washing child(ren) dishes Yes
Pick-up child(ren) areas (play
area, bedroom, children Yes
belongings)
Making child(ren) beds Yes
Laundry of child(ren) clothes Yes
Vacuuming / Dusting
Yes
child(ren) rooms
Bathing child(ren) Yes
Changing infant diapers No
Being home when children
absent from school (illness, No
vacation, etc)
Other:

Infants
Infant’s Name: Age: Comments for infants (children under 2 years old)
Jacob 2 Bruinsma

3. Compensation, Vacation, & Education

3.1 The Host Family agrees to pay the Au Pair at least the minimum weekly stipend of $195.75 (and if the Au Pair is in
EduCare, $146.81). Host Families and Au Pairs are free to agree to compensation higher than the legally applicable
minimum. The stipend is subject to the DOS Regulations, the higher of federal or state minimum wages laws, and in
conformance with the Fair Labor Standards Act as interpreted by the United States Department of Labor. Should the federal
or state regulations change, the updated stipend must be used when they go into effect. The Host Family will provide the Au
Pair with accommodations and meals. (Reg. 62.31.j.1) The Host Family acknowledges and agrees:
• The Au Pair’s stipend cannot be withheld for loss of time through illness.
• The Host Family will not reduce stipend payments to the Au Pair except for bills produced pursuant to in this Child Care
Agreement.

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 151 East 6100 South, Suite 200
CHILD CARE SERVICES Murray, Utah 84107
801.255.7722 801.255.7782 fax
AGREEMENT www.GoAuPair.com

• The Host Family will reimburse the Au Pair for all reasonable out of pocket expenses incurred in the performance of Child
Care Services provided they are approved by the Host Family and receipts are provided when requested.
• The Host Family will pay for the Au Pair’s education costs and in pursuant to section 3.5, either to the Au Pair or directly
to the secondary institution.
• The Au Pair is responsible for all other personal costs.
• At the current time, the Au Pair stipend is not subject to withholding tax or FUTA (See the IRS link -
http://www.irs.gov/Individuals/International-Taxpayers/Au-Pairs).
• The Au Pair is responsible for all income taxes paid under this Child Care Agreement.
• Should this Child Care Agreement be terminated, all vacation pay and education tuition allowances will be pro-rated
using the number of weeks the Au Pair lived with the Host Family over a 50-week year.

Stipend: When to be Paid:

Weekly stipend is $ _195.75____ Frequency Paid: Weekly

3.2 The Au Pair will prepare a hardcopy weekly log of the hours worked by day, stipend paid, vacation days used, and
educational financial contributions made (“Hours & Wages Log”). The Parties agree to review the information, and when
correct, approve with initials. If there are any discrepancies or missed initials lasting more than 14 days, any Party will notify
the LAR and Headquarters in writing to mediate any open points. (Reg. 62.31.j.1-4)

3.3 The Au Pair will be responsible for paying his/her routine personal costs, some of which the Host Family may pay in
advance. The Host Family will provide the Au Pair with written, itemized statements of these costs for which the Au Pair will
reimburse the Host Family. The reimbursable costs (“Reimbursable Costs”) are listed below; additional costs need to be
agreed to in advance.

Reimbursable Costs - Incurred by

the Host Family / Reimbursed by Yes/No Comments
Au Pair to Host Family
Travel (personal only) - gas & tolls No

Phone Bill (personal only) Yes

On our family plan, any international calls would be charged.
Other:

________________________

3.4 The Host Family agrees to provide the Au Pair two (2) weeks paid vacation at the Au Pair’s normal weekly stipend
each year at a mutually determined time following Au Pair’s arrival. The Au Pair will accrue vacation pay on a pro rata basis
in the Vacation / Education Table attached. Optionally, paid holiday(s) are described below. Go Au Pair recommends these
be offered as part of the cultural experience. (Reg. 62.31.j.4)

Vacation timing (may be

mutually defined later): Negotiable but of course we need notice.

Holidays: 1. ______ 2. ________

3. ____ 4. ______

Vacation Time for a Full Placement:

Vacation Weeks & Days Transition Au Pair Only
12 Month including Extension Extension Vacation
Vacation Pay ($)
Extension (12 Mos.) (9 Mos.) (6 Mos.) Weeks
All Au Pair Types 2 weeks = 1.5 weeks = 1 week = See - Line A attached
14 days 10.5 days 7 days Vacation/Education Table

3.5 The Au Pair is required to register and attend classes to complete at least six semester credit hours (12 semester
credit hours for an EduCare Au Pair) in a formal educational setting offered at an accredited post-secondary institution during

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 151 East 6100 South, Suite 200
CHILD CARE SERVICES Murray, Utah 84107
801.255.7722 801.255.7782 fax
AGREEMENT www.GoAuPair.com

a 12 month Au Pair Program. The Au Pair is required to provide supporting documentation for the education credits to Go Au
Pair. The Host Family agrees to facilitate the enrollment and attendance of the Au Pair in the academic program by providing
adequate time and transportation to attend classes. The Host Family agrees to provide the Au Pair the amount specified
below for tuition/costs. The Au Pair will accrue tuition costs on a pro rata basis in the Vacation / Education Table attached
(Reg. 61.31.c.3; 61.31.k.1)

Education Tuition for a Full Placement:

12 Mo & Extensions (9 & 12
Extension 6 Mos. Transition Au Pair Only
Mos.)
Educatio
Education Education Education
Tuition Costs Tuition Costs n
Au Pair Program Semester Semester Semester
($) ($) Contribut
(Hours) (Hours) (Hours)
ion ($)
All other than EduCare 6 $ 500 3 $ 250
See - Line A attached
Vacation/Education
EduCare 12 $ 1000 6 $ 500
Table

4. Au Pair Bedroom & Accommodations

The Host Family will provide a suitable, private bedroom (with a door that closes) for the Au Pair in any of the residences
where Child Care Services are provided and the Au Pair sleeps as described below. (Reg. 62.31.e.6)

What Amenities
Nice big room, separate Nice big room, separate staircase,
Describe the Au are provided in the
staircase, separate hallway. separate hallway.
Pair’s bedroom Au Pair’s
bedroom?

Large private room, tub, tile floor, Will the Au Pair’s

Describe the Au Private
newly installed in 2015. bathroom be
Pair’s bathroom
shared or private

The Host Family will Liz is vegan, Pete is not, so there is

provide the Au Pair Optional: Describe a variety of vegetables and meat
with at least one other amenities, around for eating. Generally locally
Cell phone
means of benefits or sourced food. House is big, easy to
communication. accommodations escape. WiFi good, computer or
Select all that apply. for the Au Pair. laptop is available if needed.

5. Transportation and Use of Car

5.1 If the Au Pair is to operate any vehicle, the Host Family agrees to:
• Determine that the Au Pair has sufficient driving ability to do so
• Ensure that the Au Pair has a valid driver’s license
• Provide at least the minimum mandatory car insurance at the Host Family’s expense for the Au Pair
• In case of an accident, the Au Pair will only be responsible for the actual costs of damages not covered by insurance up
to a maximum of a $500 per incident where the Au Pair is deemed to be at fault.
• Pay for gas, tolls, and parking for the vehicle(s) used by the Au Pair to perform Child Care Services or when driving
to/from LAR Cultural Events (defined Section 10.1) and/or classes which are requirements of the Au Pair Program.
• Supervise the Au Pair’s use of the automobile.

Driving Required for child Yes Will your Au Pair have Limited access
care: access to a car for
personal use?
Home Area Type: City - midsize Vehicle Used Shared

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 151 East 6100 South, Suite 200
CHILD CARE SERVICES Murray, Utah 84107
801.255.7722 801.255.7782 fax
AGREEMENT www.GoAuPair.com

Traffic volume: City - midsize Type of Vehicle Car-medium

Transmission Automatic

5.2 If the Au Pair does not have access to a car, the Host Family will provide suitable, safe transportation between the
Host Family’s residence and the educational institution and the LAR Cultural Events.

Public Transportation Available Comments

We offer bus passes if you'd like. We also have a

Bus;Train;Taxi / Ride Share
nice bicycle for you to use.

6. House Rules, Curfews, & Restrictions (See below)

Any house rules concerning restrictions or curfews are defined below.

Au Pair Visitor(s)
We would like for you to have fun and be content. Please let us know in advance about visitors. We have
We rarely have anything to say about social or after play dates sometimes with other Au Pairs.
Weekday
work activities.

We would like for you to have fun and be content. Please let us know in advance about visitors. We have
We rarely have anything to say about social or after play dates sometimes with other Au Pairs.
Weekend
work activities.

Other

7. Administering of Routine Medicine

Host Family agrees the Au Pair is not responsible for the diagnosis of any medical condition, the dispensing of any medicine,
or the provision of medical or therapeutic treatment (“Special Treatment”) for the Host Family’s children. The Au Pair has no
verified medical training. If the Host Family’s child requires medicine(s) which have been routinely administered in the past by
a Parent and can be performed by a layman with no special training (“Layman Treatment”), the Host Family may request the
Au Pair to administer this Layman Treatment if the Parties agree to the following:
i.) Host Family supervises and fully trains the Au Pair in the Layman Treatment;
ii.) Host Family is fully responsible for any acts or omissions by the Au Pair in the Layman Treatment;
iii.) Host Family and Au Pair agree to sign the Medical Consent Form for each child which details the Layman
Treatment.
Go Au Pair does not recommend the Host Family to allow the Au Pair to provide Layman Treatments due to the
potential risks including without limitation: Au Pairs are not familiar with medical names nor standards in the United States,
there may be language misunderstandings related to the use of English versus metric measures, or potential medical
complications. The Parties agree Go Au Pair and any party associated with Go Au Pair have no involvement with Laymen
Treatment or Special Treatment and have no liability of any type in connection with any intentional or negligent acts or
omissions by the Au Pair or the Host Family arising from the Layman Treatment or Special Treatment.

8. Au Pair Program Guidelines and DOS Regulations

8.1 The Parties have read, understand, and agree to abide the DOS Regulations.
8.2 Either a Parent or other responsible adult will remain in the home for the first three days following the Au Pair’s
arrival. (Reg. 62.31.e.1)
8.3 The Parties understand the Au Pair cannot accept employment of any type outside of Child Care Services with the
Host Family. If the Au Pair engages in unauthorized employment, he/she is in violation of the Au Pair Program and subject to
termination. (Reg. 62.16.b)
8.4 The Host Family agrees to maintain liability and casualty insurance to cover any reasonably foreseeable damages
which may be sustained by the Au Pair while in our household.
8.5 The Parties agree they have received the Mediation Policy and will use it whenever there are concerns affecting the
relationship between the Host Family and the Au Pair or related to the Au Pair providing Child Care Services. The Parties
agree Go Au Pair will attempt to mediate any issues and disputes between the Host Family and the Au Pair after reviewing
the available written documentation and that Go Au Pair Headquarters decisions are final. (Reg. 62.31.f.1)

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 151 East 6100 South, Suite 200
CHILD CARE SERVICES Murray, Utah 84107
801.255.7722 801.255.7782 fax
AGREEMENT www.GoAuPair.com

8.6 For an Au Pair to participate in the extension program as defined in the DOS regulations, the extension application
and documentation verifying the educational requirements must be submitted 51 days before the Au Pair’s Form DS-2019
expires.
8.7 The Parties agree to use reasonable efforts to ensure the Au Pair leaves the United States by the End Date plus the
30 day grace period (“Grace Period”). If the Au Pair does not leave the United States before the end of the Grace Period, Au
Pair is at risk of penalties dictated by federal law. (Reg 62.13.c.1 ) The Parties further acknowledge that Go Au Pair cannot
support nor sponsor the Au Pair for a change of visa status or visa program.
8.8 The Parties agree the use of recording device (“Recording Device”), including but not limited to a “nanny cam”, shall
be limited to the purpose of evaluating the Au Pair’s performance with the child(ren) in the Au Pair’s care, and shall be limited
to common areas of the home, in which the Au Pair provides Child Care Services. Recording Devices shall not be used in
any area of the Host Family’s home in which an Au Pair has reasonable expectation of privacy, including but not limited to
bathrooms and bedroom used by the Au Pair.

Recording Devices

Will the Host Family be using one or more Recording Devices in the home? No

9. Insurance
Go Au Pair provides the Au Pair with basic accident and illness insurance coverage which ends on the End Date.
• Upgraded coverage is recommended and available for purchase by the Host Family or Au Pair through Go Au Pair for
a one-time annual fee
• Coverage for the Grace Period is available for an additional cost and is highly recommended.

10. Cultural Events

10.1 The Parties understand the Au Pair is required to attend at least four (4) cross-cultural activities (“LAR Cultural
Events”) throughout the 12 months in the Au Pair Program, or prorated if less than 12 months. These cross-cultural activities
are designed to promote exposure and interchange between exchange visitors and Americans so as to increase their
understanding of each other's society, culture, and institutions. The Host Family agrees to support attendance and provide
the Au Pair with the necessary time off and transportation for the LAR Cultural Events. (Reg. 62.8.d.1-2)
10.2 As required by the Au Pair Program the Host Family agrees to attend one family day event, arranged by the LAR,
during the Au Pair’s stay in the United States. (Reg. 62.31.i.3)

11. Communications with Go Au Pair

11.1 The Parties agree to respond to inquiries and maintain communication with the LAR in their monthly contacts to
monitor the placement and to take advantage of the Au Pair Program’s resources. This includes both routine matters and
issues while the Au Pair is living in the Host Family’s home. Parties agree to promptly notify the LAR in writing of any
emergency matters, unusual or serious incidents, or problems arising from the Au Pair’s participation in the Au Pair Program,
especially situations that could potentially affect the Au Pair’s completion of the Au Pair Program. This includes without
limitation: adherence to DOS regulations, hours or wages, performance/quality of services, quality of relationship between
the Au Pair and Host Family or Au Pair and children, and the overall satisfaction of each Party with the Au Pair Program, etc.
Reg. 62.31.
11.2 The Parties agree the communications and support provided during the Au Pair Program by Go Au Pair including
without limitation by any LAR’s, employees, agents, do not represent any form of supervision of the Child Care Services or
imply any responsibility for the Au Pair’s performance.

12. Confidential Information

During the course of the Au Pair’s employment, the Parties will legitimately become privy to confidential information about one
another. Confidential information (“Confidential Information”) includes, without limitation, pictures, videos, email addresses,
financial information, personal telephone numbers, birth dates, and Social Security numbers. Confidential Information may
not be disclosed to anyone or in any public forum, including without limitation, Facebook, Twitter, Instagram, LinkedIn,
MySpace, YouTube, social networks, internet sites, or personal blogs without the prior written consent of the other Party.

13. Termination of Contract

13.1 This Child Care Agreement will terminate on the End Date specified in the Au Pair’s Form DS-2019.
13.2 To terminate this Child Care Agreement before the End Date, the Parties must follow the Mediation Policy, especially
Step 3. The party(ies) requesting to terminate this Child Care Agreement must notify Headquarters in writing via email, fax or
written letter requesting the placement be terminated (“Notification”);
13.3 Both Party must submit the written Incident Report from their point of view;
13.4 The Party terminating this Child Care Agreement must give two (2) week notice (“Transition Period”) unless otherwise
mutually agreed by the Parties.

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 151 East 6100 South, Suite 200
CHILD CARE SERVICES Murray, Utah 84107
801.255.7722 801.255.7782 fax
AGREEMENT www.GoAuPair.com

13.5 Outstanding charges for the Au Pair’s personal expenses as defined in this Child Care Agreement may be deducted
from his or her final paycheck. The Au Pair may have a financial obligation to the Host Family if the final paycheck does not
cover outstanding charges.
13.6 The Host Family agrees pay to the Au Pair vacation pay and tuition allowance based on the number of weeks used in
the placement and shown on Vacation / Education Table attached. Vacation pay and education allowance are accrued
weekly. The Weekly prorate amounts are calculated by dividing the total amounts due to the Current Au Pair in the
placement by the number of weeks in the placements less 2 weeks.
• Vacation pay – the Current Au Pair must be paid at least the minimum allocated amount shown.
• Education allowance – The Current Au Pair is owed additional education allowance if, the number of credit hours and
tuition costs after any refund from the institutions (“Tuition Costs Spent”), fall below the allocated amounts in the
Vacation / Education Table. The amount to be paid is the lower of:
a.) the tuition costs in the Vacation/Education Table for prorated Tuition Cost less the Tuition Costs Spent or
b.) the number of credit hours below the amounts in the Vacation / Education Table times the dollar cost / credit.
• The Current Au Pair is required to provide supporting documentation for the education credits.
• Go Au Pair will provide a record of the Placement Start Date and end dates of this placement (“Placement Completion
Worksheet”). We and the Current Au Pair must complete and sign the Placement Completion Worksheet to mutually
confirm the status of payments for pro-rata vacation and tuition, stipend, and any other open issues including debts
owed or other property to be returned.
13.7 The Parties must complete and sign the Placement Completion Worksheet to confirm the status of payments for pro-
rata vacation and tuition, stipend, and any other open issues including debts owed or other property to be returned.
13.8 If the Au Pair terminates this Child Care Agreement within the first 90 days of arriving at the Host Family’s home, then
the Au Pair must reimburse Go Au Pair for his or her airfare cost as below. Go Au Pair will then return the reimbursed airfare
to the Host Family in the form of a credit or refund, absent the Host Family violating the Au Pair Program regulations as
determined by Go Au Pair.
• Between 0 to 60 days at 100% of his or her airfare cost
• Between 61 to 90 days of arrival at 50% of his or her airfare cost

14. Other Terms

14.1 The Parties and their heirs, predecessors, successors and assigns completely release and forever discharge Go Au
Pair, its past, present and future officers, managers, members/owners, agents, representatives, employees, consultants,
independent contractors, attorneys, insurers, parent companies, subsidiaries, and affiliates, (collectively, the “Released
Parties”), from any and all past, present or future claims of any kind, including but not limited to, claims for pain, suffering,
personal injuries, attorney’s fees, costs, loss of services, mental anguish, disability, medical and hospital expenses, lost
wages or earning capacity, all special and general damages, consequential and punitive damages, whether based on a tort,
contract, statutory or other theory of recovery (“Claims”), on account of or in any way arising from, the hiring, placement, or
employment of an Au Pair, any activities in the Au Pair Program, the provision of Child Care Services, or from an Au Pair’s
intentional or negligent acts, or omissions.

14.2 The terms and conditions of this Child Care Agreement shall be construed under the laws of the State of Utah. The
Parties agree that any dispute among them that is not settled informally will be submitted to binding arbitration, to be
conducted in substantial accordance with the rules of American Arbitration Association by a single arbitrator. The identity of
the arbitrator will be decided by mutual agreement, with the arbitrator’s fee to be shared equally between the Host Family and
Au Pair. The decision of the arbitrator shall be final and cannot be appealed. If the Parties cannot agree on an arbitrator then
the AAA will appoint one. By signing this Child Care Services Agreement, the Parties waive their right to have any claim
against the other heard in any court by a judge or jury, although each Party retains the right to have a court enforce an
arbitration award in accordance with the law.

14.3 If any of the terms or conditions of this Child Care Agreement are found to be illegal, invalid, or otherwise
unenforceable, such term shall not affect the remaining terms and conditions of this Child Care Agreement, and such term or
condition shall be deemed modified to the extent necessary in the arbitrator’s opinion to render such term or condition
enforceable, preserving to the fullest permissible extent the intent and agreements of the parties.

14.4 This Child Care Agreement may be signed in counterparts and may be delivered by facsimile signature or electronic
signature under the provisions of the US ESIGN Act. A facsimile or electronic signature shall be considered the same as an
original.

14.5 The Parties each acknowledge this Child Care Agreement sets forth the entire agreement between them related to the
Au Pair Program, and neither has relied on any warranties or representations other than set forth. This Child Care
Agreement may be modified or amended only by the mutual written agreement of the Parties.

14.6 The Parties agree changes in the DOS Regulations and DOS formal guidelines governing the Au Pair Program
supersede and amend any portion of this Child Care Agreement.

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 151 East 6100 South, Suite 200
CHILD CARE SERVICES Murray, Utah 84107
801.255.7722 801.255.7782 fax
AGREEMENT www.GoAuPair.com

15. Definitions
15.1 “Special Care” means individuals (child or adult) identified by the Host Family with special health care needs
(“CSHCN”) as “those who have or are at increased risk for a chronic physical, development, behavior, or emotional condition
and who also require health and related services of a type or amount beyond that required by children generally” using the
US Department of Health & Human Service (DOHHS). This could include without limitation any of the following areas:
breathing, swallowing/digestion/metabolism, blood circulation, chronic pain, hearing even with corrective devices, seeing even
with corrective devices, taking care of self, coordination/moving around, learning/understanding/paying attention,
speaking/communicating, making/keeping friends, and behavior.

16. Parties Representations

Each Party warrants that all the information given to the other Party is true, accurate and complete. Each Party has
thoroughly reviewed the other Party’s application and personally interviewed the other Party by telephone, or the
equivalent, in English at least two times prior to entering into this Child Care Agreement. Each Party warrants it has
carefully reviewed the terms and conditions outlined herein and agrees to abide by them as acknowledged by his or
her signature below. (62.31.e.7)

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Signature – Host Family Print Name Date

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Signature – Au Pair Print Name Date

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 Medical Consent 151 East 6100 South, Suite 200
Murray, Utah 84107
801.255.7722 801.255.7782 fax
Form www.GoAuPair.com

This Medical Consent Form (“Medical Consent”) gives the Au Pair permission to administer Layman Treatment(s) to the child named in the
manner described. This Medical Consent Form is agreed to by the host family (“Host Family”) and the au pair (“Au Pair”) if both are signed
below (collectively “Parties”). The Au Pair is not required to sign this Medical Consent and perform these tasks.

Child Care Service Agreement prevails if there are any conflicts. Summary points include below:
1. This Medical Consent is an attachment to the Child Care Services Agreement previously signed by both Parties.
2. Submit the signed Medical Consent to Go Au Pair Headquarters within 24 hours of signing and before the Au Pair performs the
requested tasks.
3. Both Parties understand that the Au Pair shall not be responsible for Special Treatments.
4. Both Parties agree the Host Family will supervise and fully train the Au Pair before performing any steps. The Host Family is
solely responsible for acts or omissions of the Au Pair.
5. Both Parties agree the named Parent(s) below are the parent or legal guardian for the child named in this consent form.
6. Both Parties understand the Au Pair has permission to provide basic first aid for the child named and to take the appropriate measures
including contacting emergency medical services and arranging transportation to the nearest medical facility to receive the appropriate
level of care as determined by qualified medical professionals.
7. Both Parties understand the Au Pair will attempt to contact, as defined below, the parent or legal guardian specified in the event the
child is injured or ill.
8. Go Au Pair and its representatives have no involvement with Layman Treatment and have no Liabilities in connection with
Layman Treatment for any intentional, unintentional, negligent or gross negligent acts or omissions by the Au Pair or the Host
Family.

Jacob
Name of Child: Medication 1:
Jacob Dosage & Administration Instructions:
Date of Birth: Special Instructions:
9/5/2017 Storage Instructions:
Medical Condition(s) or Concern: Possible Side Effects:
Signs or Symptoms to note:
Allergies of any type: Medication 2:
Layman’s Treatment? Dosage & Administration Instructions:
No Special Instructions:
Storage Instructions:
Physician(s) for treating medical condition (if applicable) Possible Side Effects:
IN CASE OF EMERGENCY: Dial 9-1-1
Name 1: Medication 3:
Phone Number 1: Dosage & Administration Instructions:
Name 2: Special Instructions:
Phone Number 2: Storage Instructions:
Possible Side Effects:
Pharmacy(ies) where medication was filled:
Store/Location 1:
Phone Number 1:
Store/Location 2:
Phone Number 2:

Other instructions / information:

Parent/Legal Guardian’s Contact Information: (616) 706-2736

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Parent/Legal Guardian: Signature Printed Date (mm/dd/yy)

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Au Pair: Signature Printed Date (mm/dd/yy)

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