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PERSONAL REFERENCE

The applicant presenting you with this form is a candidate for the AuPairCare program. If accepted, he/she will spend a year with an American family taking care of and being responsible for the children in this family. NOTE: This reference must be complet ed by a NON-RELATIVE and wi l l be veri f ied by an AuPairCare

represent at ive. You may be cont act ed t o veri f y t his reference.

1. Name of applicant:_______________________________________________________________________________ 2. How long have you known this applicant? __________________________________________________________ 3. How do you know this applicant?

Employer Neighbor Teacher Friend Colleague Other _____________________________________

4. How would you describe this person�s character? Active Family-oriented Open-minded Sociable Adaptable Flexible Outgoing Sporty Creative Humorous Polite Warm-hearted Efficient Independent Positive Other ______________________

5. Please describe why you believe the applicant is suitable for the AuPairCare program. List any relevant skills and abilities the applicant has demonstrated: ___________________________________________________________________________________________________

___________________________________________________________________________________________________

___________________________________________________________________________________________________ 6. Do you recommend this applicant for the AuPairCare program? Yes No Please explain: ___________________________________________________________________________________________________

___________________________________________________________________________________________________

___________________________________________________________________________________________________ 7. Additional comments on the applicant�s character: ___________________________________________________________________________________________________

___________________________________________________________________________________________________

___________________________________________________________________________________________________ 8. Reference Information: Name: _____________________________________________________________________________________________ Address: ___________________________________________________________________________________________

Signature: ____________________________________________________________ Date: ______/______/________ 9. May a prospective host family call you? Yes No, I am uncomfortable speaking English.

Email Address: _______________________________________ Daytime Phone: (011) ____________________________ Evening Phone: (011) _____________________________ Country Code/Local Number Country Code/Local Number

For Office Use Only Verified by: ___________________________________________________ Date: _____/_____/_____

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Historial Médico Verificado por un Médico

Nota al Médico: La persona que le solicita este certificado, ha solicitado una plaza para la posición de au pair en EE.UU. Si el/la candidato/a es aceptado, el/ella pasará un año con una familia estadounidense cuidando los niños de la familia y siendo responsable por ellos. Es importante que las personas a quiénes confiamos este trabajo gocen de buena salud. Por favor, proporcione su historial médico detalladamente y añada cualquier información que pueda ser necesaria.

Nombre del paciente: _ _ _ Fecha de nacimiento (mes/dia/ año): _/ _/ _

Edad: _ _ Altura: _ Peso: _ _ _ _ _

1. ¿Ha padecido este paciente alguna vez de o ha sido diagnosticado con alguno de los siguientes? Por favor indíquelo, haciendo una cruz en Si y

No para cada condición:Alguna enfermedad o anormalidad de: Salud general:

Si No Anorexia Alergias Bulimia Varicela Diabetes Epilepsia Hernia HIV/Sida Hepatitis Sarampión

Si No Meningitis Paperas Rubéola Fiebre Escarlata Tos severa o persistente Dolores de cabeza serios o

persistentes Tuberculosis Fiebre tifoidea Ulcera

Vertigo/ Mareo

Si No Sistema endocrino o cardiovascular Huesos, articulaciones, o locomotora Cerebro o sistema nervioso Oído o audición Ojos o visión Corazón Pulmones o sistema respiratorio Otros órganos abdominales Estomago o digestiva Amígdala, nariz o garganta

Si No Asuntos genito-urinarios Disturbios mentales o nerviosos ¿Esta la paciente embarazada? ¿Tiene el/la paciente una minusvalía física? ¿Tiene el/la paciente una

enfermedad contagiosa? ¿Tiene el/la paciente una dependencia de

alcohol o de drogas? ¿Sufre el/la paciente de ataques de pánico? ¿Fuma el/la paciente?

Otros::

Si ha indicado Si en alguna de la condiciones mencionadas arriba, por favor explique en detalle y indique el año en que la(s) enfermedad(es) ocurrió

(/ocurrierón). Si el año exacto es desconocido, por favor indique un año aproximado:

_ _ _

_ _ _

_ _ _ _

_ _ _ _

2. Por favor liste todas las inoculaciones/ vacunas/ inmunizaciones que han sido dadas a este/a paciente de adulto/a y el mes y año aproximados:

_ _ _ _ _ _ _

_ _ _ _ _ _ _

3. ¿Ha sido este/a paciente alguna vez hospitalizado? Si No

Se si, por favor explique:

_ _ _

_ _ _

_ _ _ _

_ _ _ _

4. ¿Ha sido este/a paciente tratado en los últimos dos años de alguna condición médica? Si No

Se si, por favor explique: _

_ _

_ _

_ _

_

_

_ _ _ _

_ _ _ _

_ _ _ _

5. ¿Toma el/la paciente alguna medicación con regularidad (excluyendo anticonceptivos)? Si No

Se si, por favor explique:

_

_ _ _

_ _

_ _ _ _

_ _ _ _

_ _ _ _ _ _ _

6. ¿Sufre este/a paciente de alguna condición pre-existente? Si No

Se si, por favor explique: _ _ _ _ _ _ _

_ _ _

_ _ _

_ _ _ _

_ _ _ _

7. ¿Ha recibido este/a paciente alguna vez asesoramiento psicológico? Si No


_ _ _ _ _ _ _

_ _ _ _ _ _ _

Rev. 04/2013

8. ¿Tiene el/la paciente un historial o síntomas de una disturbio alimentar, tal y como la anorexia, bulimia u otras condiciones semejantes? Si No

Se si, por favor explique: _ _ _ _ _

_ _ _ _ _

_ _ _ _ _

_ _

_ _

_ _

9. ¿Presenta el/la paciente un historial o síntomas de una anormalidad nerviosa, emocional o mental (i.e. neurosis, depresión nerviosa,fatiga nerviosa, pesadillas recurrentes, ataques de pánico, etc.)? Si No

Se si, por favor explique: _ _ _

_ _ _

_ _ _ _

_ _ _ _

_ _ _ _ _ _ _

10. ¿Sufre este/a paciente de alguna condición crónica (i.e. asma, artritis, diabetes, epilepsia, fatiga crónica, etc.)? Si No


_ _ _

_ _ _ _

_ _ _ _

_ _ _

11. ¿Ha sido el/la paciente alguna de vez victima de abuso físico o sexual? Si No

_ _ _ _


_ _ _ _ _ _ _

_ _ _ _ _

12. ¿Hay alguna razon por la cual este/a paciente no debería cuidar a niños? Si No

_ _


_ _ _

_ _ _

_ _ _ _

_ _ _ _

_ _ _ _

13. ¿Hay cualquier otra cosa que le gustaría decir sobre este/a paciente? Si No


_ _ _

_ _ _

_ _ _ _

_ _ _ _

_ _ _ _

14. En mi opinión de experto, el estado general de salud del paciente es:

Excelente Buena Regular Pobre

Yo, el abajo firmante, he hecho un examen físico riguroso al/ a la paciente y revisto su historial medico. Yo certifico que la información arriba mencionada es completamente correcta en mi conocimiento.

Nombre del médico: _ _

Número de teléfono: _ _

Firma: _ _ _ Sello del medico aqui

Fecha (mes/ dia/ año): _ _/ /_ _

Rev. 04/2013 2

2014 AU PAIR AGREEMENT

rev 05/05/ 2014 Au Pair’s Initials__________

Page 1 of 6

This AuPairCare Au Pair Agreement (t he “ Agreement ” ) is ent ered int o bet ween AuPairCare, a Cal ifornia Corporat ion and “ Au Pair” (f irst and last name of Au Pair) ________________________of (Cit y) ______________________, (Count ry) __________________” . Au Pair has ful ly read t his Agreement and agrees t o t he t erms and condit ions cont ained herein. “ Host Family” is t he family in t he Unit ed St at es

wit h whom Au Pair has agreed t o mat ch, and wit h whom Au Pair wil l l ive and work.

A. General Provisions

Au Pair is hereby advised and acknowledges t hat t he part ies agree as fol lows:

1. Au Pair wil l abide by t he t erms and condit ions of t his Agreement for t he durat ion of Au Pair’ s part icipat ion in t he AuPairCare program, unless and unt i l t his Agreement is replaced or modif ied by a subsequent writ t en agreement execut ed by AuPairCare and Au Pair.

2. Au Pair is hereby advised and acknowledges t hat al l Au Pairs are part icipant s in a cul t ural exchange program, and agrees t o comply wit h

al l of t he regulat ions publ ished by U.S. Depart ment of St at e in 22 CFR Part 514, as t he same may be amended f rom t ime t o t ime in t he fut ure (“ t he Regulat ions” ). Said regulat ions can be found by visit ing: ht t p: / / j 1visa.st at e.gov/ programs/ au-pair

3. Au Pair underst ands t heir right s as visa part icipant under t he Wilberforce Traf f icking Vict ims Act . Said r ight s and resources for can be

found by visit ing: ht t p: / / t ravel .st at e.gov/ content / visas/ engl ish/ general / right s-prot ect ions-t emporary-workers.ht ml

4. Au Pair represent s t hat al l informat ion provided t hroughout t he appl icat ion process is t rue and t hat no relevant informat ion has been

excluded or misrepresent ed in t he appl icat ion process and document s, including represent at ion of t he level of Engl ish prof iciency, healt h and/ or childcare experience. Au Pair agrees t hat al l such disclosures wil l be ful l and accurat e, up t o and t hrough t he dat e of

depart ure f rom Au Pair’ s count ry of origin.

5. Au Pair agrees t o complet e al l visa screening requirement s in accordance wit h t he inst ruct ions given and wil l be responsible for obt aining a val id passport and complying wit h al l vaccinat ions and immunizat ion requirement s.

6. Au Pair agrees t o immediat ely amend any disclosures should new informat ion become available to Au Pair in any regard or at any t ime

of part icipat ion in t he program. Au Pair represent s t hat s/ he wil l personal ly conduct al l writ t en and phone correspondence wit h Host Family during t he int erviewing process. Au Pair underst ands t hat exaggerat ion or falsif icat ion of any appl icat ion informat ion by Au Pair,

references or Originat ing Exchange Organizat ion may result in immediat e dismissal f rom t he program and ret urn t o Au Pair’ s home count ry at Au Pair’ s expense.

7. AuPairCare has t he exclusive right t o det ermine suit abil it y of Au Pair t o part icipat e in t he program bot h before and during part icipat ion in t he program. Au Pair agrees t hat in det ermining suit abil it y, AuPairCare may make inquiries t o t hird part ies about Au Pair, including

but not l imit ed t o medical personnel and insurance agencies ot herwise covered by federal HIPAA regulat ions.

8. Au Pair underst ands t hat t hey cannot be married, engaged t o be married or have children of t heir own and part icipat e in AuPairCare’ s au pair program.

9. Au Pair is not an employee, agent or independent cont ract or of AuPairCare, and AuPairCare does not exercise dominion or cont rol over

t he act ions of t he Host Family.

B. Fees and Program Costs

10. Part icipat ion in t he AuPairCare program requires Au Pair t o pay a non-refundable program fee t o Originat ing Exchange Organizat ion. 11. Originat ing Exchange Organizat ion may charge Au Pair addit ional fees t o cover t heir administ rat ive cost s in promot ing t he AuPairCare

program and processing au pair appl icat ions. The fees may include, but are not l imit ed t o, an appl icat ion fee, processing fee, handl ing fee, and int erview fee. These fees may vary across Originat ing Exchange Organizat ions. AuPairCare assumes no dut ies or

responsibil i t ies for any act s or omissions of t he Originat ing Exchange Organizat ion regarding addit ional fees.

12. Au Pair wil l be responsible for addit ional cost s, including but not l imit ed to, baggage check fees for arrival and ret urn f l ight s, personal expenses while at t he Au Pair arrival orient at ion, medical expenses not covered by insurance and al l incident als and personal expenses

while on t he program. Au Pairs should be prepared t o cover t hese cost s.

13. Au pair wil l pay al l appl icable fees to Originat ing Exchange Organizat ion before beginning t ravel t o t his Unit ed St at es. Au Pair may not under any circumst ances sol icit funds f rom Host Family for t o cover personal cost s of program, including but not l imit ed t o fees due t o

t he Originat ing Exchange Organizat ion, cost s associat ed wit h securing a visa, or incident al t ravel cost s. 14. Au Pair agrees t hat s/ he has adequat e f inancial resources t o sat isfy al l obl igat ions as an AuPairCare Au Pair, including payment for a

ret urn f l ight if Au Pair does not successful ly complet e t he program.

C. Au Pair Cancellations/ Flight Change Requests

15. Au pair agrees t o pay a $300.00 USD cancel lat ion fee, plus the actual cost of international and/ or domestic airfare (if t ravel has been

arranged), in t he event he/ she cancel f rom t he program af t er mat ching wit h a family but prior t o arrival at t he host family home.

16. Au pair agrees t o pay a $300.00 USD change fee and any applicable airfare penalties, in t he event he/ she request s t o change t heir

arrival dat e.

D. Responsibilities

17. Au Pair underst ands t hat during t he f irst t hree (3) days of an au pair’ s st ay in t he home, a parent or anot her responsible adul t shal l

remain in t he home t o facil it at e t he adj ust ment of t he au pair int o t he family, household and communit y.

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18. Au Pair agrees t o perform childcare services and l ight housekeeping relat ed t o childcare t hat shal l not exceed fort y-f ive (45) hours per

week, f ive and one half (5 1/ 2) days per week, wit h a maximum of t en (10) hours per day. Au Pair wil l have one ful l weekend of f per mont h (Friday evening t o Monday morning). If a disput e arises as t o any of t hese l imit s or requirement s, AuPairCare shal l resolve said

disput e, and it s decision shal l be f inal.

19. Au Pair’ s responsibil i t ies wil l be l imit ed t o childcare and child-relat ed t asks for t he Host Family. This may include dut ies such as general supervision, preparing and cleaning up af t er children’ s meals, st raight ening children’ s rooms, doing children’ s laundry, preparing t he

children for school, assist ing wit h homework, and being present when children are sleeping. The Au Pair’ s responsibil i t ies wil l not include heavy housework, yard work or ot her non-child relat ed labor for t he household. If a disput e arises concerning t he scope of t he

Au Pair’ s responsibil i t ies, AuPairCare shal l resolve said disput e, and it s decision shal l be f inal .

20. Au Pair underst ands t hat U.S. Depart ment of St at e regulat ions prohibit Au Pair employment beyond t he au pair arrangement wit h t he Host Family. Au Pair may not undert ake any ot her paid work while in t he U.S. , including babysit t ing for Host Family for ext ra pay beyond t he 45 hour weekly l imit , babysit t ing for ot her famil ies, or t ut oring language st udent s.

21. Au Pair is hereby advised and underst ands t hat if t here is an infant under the age of two years old in t he household, t he au pair must

have 200 hours of documented experience working with children under the age of two. Such documented experience shal l be verif ied by AuPairCare prior t o au pair placement .

22. Au Pair underst ands t hat in t he event t here is an infant under the age of three months in t he household, a parent or ot her responsible

adult shal l be present in t he home at al l t imes, and Au Pair shall not be the sole caregiver for that child at any time.

23. Au Pair agrees t o perform t he childcare responsibil i t ies t o t he best of his/ her abil it y, and make every ef fort t o act as a caring, responsible Host Family member.

E. Behavior and Comportment

24. Au Pair agrees t o abide by Host Family rules as t hey are det ermined by t he Host Family, and wil l behave as a responsible member of t he Host Family at al l t imes. If a dispute arises concerning t he Host Family rules, AuPairCare shal l resolve said disput e, and it s decision

shal l be f inal . Au Pair underst ands t hat Host Family is not required t o provide access t o a car, personal phone l ine, personal t elevision, comput er or ot her perks.

25. If Au Pair is expected or permit t ed t o drive t he family car(s), Au Pair will obtain a valid international driver’s license prior to arrival

in the United States, and if required by law, obtain a U.S. driver’s license at his/ her own expense. Failure t o do so may result in

t erminat ion f rom t he program.

26. Au Pair underst ands t hat if s/ he is expect ed or permit t ed t o drive t he family car(s), t he Host Family must provide suf f icient aut omobile insurance t o comply wit h al l appl icable laws, and which insurance shall in no event cover less t han $10,000 in medical coverage. Au pair

underst ands t hat it is t heir responsibil it y t o ensure said pol icy is act ive t hroughout t heir program part icipat ion, if t hey wil l be expect ed or permit t ed t o drive. Au Pair wil l not be responsible for payment of any aut omobile insurance deduct ibles t hat exceed $250 per

accident . Au Pair agrees never t o use t he car(s) wit hout t he express permission of Host Family or t o use t he car for purposes not approved by t he Host Family.

27. Au Pair agrees t o fol low al l local and st at e laws concerning cel l phone use and driving, and at a minimum agrees t o not use a cel l phone

while driving a motor vehicle unless it has been connect ed t o a hands-f ree device AND he/ she has received permission f rom his/ her Host Family t o use said equipment . Failure t o adhere t o t his agreement may result in immediat e t erminat ion f rom t he program.

28. Au Pair agrees not t o web surf , send, or read t ext -based communicat ion on elect ronic wireless communicat ions devices, such as cel l

phones, while driving a mot or vehicle. Failure t o adhere t o t his agreement may result in immediat e t erminat ion f rom t he program.

29. Au Pair agrees not t o hit chhike at any t ime, due t o t he dangerous nat ure of hit chhiking in t he Unit ed St at es.

30. Au Pair agrees t o exercise sound j udgment and caut ion while part icipat ing in Internet -based communit ies, dat ing and social net working

websit es such as Facebook, Orkut , MySpace or ot her sit es. Au Pair underst ands t hat Host Family informat ion, including but not l imit ed t o phone numbers, addresses, family names, informat ion about Host Family children, or phot os of Host Family home and household

members may not be post ed onl ine by Au Pair, wit hout t he Host Family’ s prior consent .

31. Au Pair agrees not t o send, receive or view inappropriat e cont ent (sexual or violent ) in t he host family home, or out side of t he home using t he host family’ s equipment (i.e. comput er, cel l phone, handheld device, t ablet , DVD player, t elevision, et c. ) by means of , but

not l imit ed t o: l ive video, phot os, pre-recorded videos, inst ant messages, sext ing/ t ext ing, social media post s/ updat es. Failure t o adhere t o t his agreement may result in immediat e t erminat ion f rom t he program.

32. Au Pair agrees not t o buy, possess or consume any cont rol led or i l legal subst ances, except t hose prescribed by a physician. Au Pair

understands that the legal drinking age in the United States is age 21, and that the legal ramifications of underage drinking in the

United States are serious and can result in immediate termination from the AuPairCare program. Au Pair agrees not t o consume alcohol ic beverages at any t ime if Au Pair is under t he legal drinking age of 21. If Au Pair is of legal drinking age, Au Pair agrees not t o

excessively consume alcohol ic beverages at any t ime. Au Pair agrees never t o drive an aut omobile af t er consuming alcohol ic beverages. Au Pair agrees never to consume alcoholic beverages while on duty caring for Host Family children. As wit h al l ot her t erms of t his

Agreement , if Au Pair violat es t his t erm of t he Agreement , AuPairCare may in it s sole discret ion t erminat e Au Pair’ s part icipat ion in t he program and immediat ely repat riat e Au Pair t o his/ her home count ry at Au Pair’ s expense.

33. Au Pair agrees t o abide by al l local, st at e and federal laws. If Au Pair is arrest ed and/ or is in pol ice cust ody under suspicion of

commit t ing a crime, AuPairCare wil l not arrange or pay for legal assist ance or represent at ion for Au Pair. Au Pair wil l be responsible for resolving any legal mat t ers independent ly and wit hout t he assist ance of AuPairCare and it s st af f . As wit h al l ot her t erms of t his


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34. Au Pair underst ands t hat t he AuPairCare program is a smoke f ree program and agrees not t o smoke while part icipat ing in t he AuPairCare

program. This includes, but is expressly not l imit ed t o, smoking in or around t he Host Family home. As wit h al l ot her t erms of t his


35. Au Pair underst ands and agrees t hat monit oring and recording devices, including but not l imit ed t o nanny cams may be implemented in common areas of t he Host Family home in order t o monit or Au Pair’ s performance and int eract ion wit h t he child(ren) whom Au Pair is

caring for, and consent s t heret o and waives any and al l claim of privacy right s wit h respect t heret o.

F. Compensation and Financial Responsibility

36. Au Pair will receive room and board in t he form of meals and a suit able privat e bedroom in Host Family’ s home, which has been approved by a local AuPairCare represent at ive.

37. Au Pair will receive a weekly stipend in accordance wit h t he U.S. Depart ment of St at e Regulat ions in t he amount of $195.75. Said

st ipend shal l be paid by t he Host Family on t he same mut ual ly agreed upon day each week in t he payment met hod chosen by t he Host Family, and cannot be wit hheld for any reason.

38. Au Pair will receive two calendar weeks paid vacation (10-days), t o be t aken at mut ual ly agreed upon t imes. Vacat ion days shal l

accrue on t he basis of one day per mont h f rom t he beginning of Au Pair’ s t hird mont h in t he U.S. During Au Pair's ext ension program, Host Family wil l provide 9-mont h and 12-mont h ext ension Au Pair wit h t wo calendar weeks (10-days) of paid vacat ion, t o be t aken at

mut ual ly agreed upon t imes. A 6-mont h ext ension Au Pair wil l receive one calendar week (5-days) of paid vacat ion. Vacat ion days shall accrue on t he basis of one day per mont h f rom t he beginning of t he Au Pair’ s t hirt eent h mont h in t he U.S. If any disput es arise concerning vacat ion issues, AuPairCare shal l resolve said disput e, and it s decision shal l be f inal.

39. Au Pair understands that he/ she is not entitled to paid or unpaid holiday time-off.

40. Au Pair will receive subsidy of educational costs f rom t he Host Family as out l ined in t he “ Training and Educat ion Requirement s”

sect ion of t his document .

41. Upon successful completion of the program, Au Pair will receive a return flight airline ticket from AuPairCare t o Au Pair’ s home count ry. Au Pair wil l be responsible for planning and paying for t ravel f rom t he int ernat ional dest inat ion airport t o Au Pair’ s f inal

dest inat ion in home count ry. Au Pair underst ands t hat in t he event Au Pair does not elect t o use t he ret urn air t icket provided by AuPairCare for any reason, no refund, credit , or t ravel voucher wil l be provided.

42. Au Pair underst ands t hat in 1994, t he U.S. Depart ment of Labor det ermined t hat t he au pair st ipend const it ut es "wages" because an

employer-employee relat ionship exist s bet ween t he au pair and t he Host Family. Au Pair’ s wages are essent ial ly in t he nat ure of household employment , and t herefore Au Pair is required to file U.S. individual tax returns, even if no taxes are due.

43. Au Pair is responsible for complying with any Federal or state labor and/ or income tax laws t hat may apply t o Au Pair. AuPairCare does not provide legal advice regarding any such laws and is not responsible for informing Au Pair of , or overseeing compliance wit h, any

such labor laws, including but not l imit ed t o Worker’ s Compensat ion laws and/ or income or ot her t ax laws which may vary f rom stat e t o st at e, and are subj ect t o change f rom t ime t o t ime.

44. Au Pair is wholly responsible for personal expenses and management of personal finances. AuPairCare shal l not be responsible for

any personal bil ls incurred by t he Au Pair or Host Family, such as (wit hout l imit at ion) t elephone bil ls, automobile expenses, t ravel expenses, and/ or healt h expenses not covered by insurance. Accordingly, Au Pair agrees not t o seek payment or assist ance in

recovering any such expenses or cost s f rom AuPairCare.

G. Travel and Accident Insurance

45. Au Pair wil l receive t ravel and accident insurance provided by AuPairCare t hrough a t hird-part y insurance carrier, and such coverage

cont ains l imit at ions and exclusions. Au Pair agrees t o review t he scope of said coverage and t he l imit at ions and exclusions cont ained

t herein prior t o arrival in t he Unit ed St at es. Said informat ion can be accessed on AuPairCare’ s websit e: ht t p: / / www.aupaircare.com/ current -au-pair/ insurance. Au Pair is advised and agrees t hat any disput es pert aining t o coverage issues

are st r ict ly bet ween Au Pair and t he t hird-part y insurance company, and agrees t hat AuPairCare is not responsible for any coverage issues and/ or disput es. Not e: This sect ion [43] does not apply t o au pairs recrui t ed by Originat ed Exchange Organizat ion; STS St udent

Travel Schools AB. STS Travel School AB au pairs should refer t o sect ion [44].

46. If recruit ed by Originat ing Organizat ion, STS St udent Travel Schools AB, Au Pair wil l receive t ravel and accident insurance provided by STS St udent Travel Schools AB t hrough a t hird-part y insurance carrier, and such coverage cont ains l imit at ions and exclusions. Au Pair

agrees t o review t he scope of said coverage and t he l imit at ions and exclusions cont ained t herein prior t o arrival in t he Unit ed St at es. Said informat ion can be accessed by visit ing www.falck.com/ t ravelcare. Au Pair is advised and agrees t hat any disput es pert aining t o

coverage issues are st rict ly bet ween Au Pair and t he t hird-part y insurance company, and agrees t hat AuPairCare is not responsible for any coverage issues and/ or disput es.

47. Au Pair understands that pre-existing medical conditions will not be covered by the third-party travel and accident insurance.

48. Au Pair understands that the dental insurance provided to them only covers injuries that are the result of an accident, and does

not cover the cost of standard dental treatment. It is t herefore important for Au Pair t o receive a t horough dent al examinat ion so

t hat no unexpect ed complicat ions arise during t he period of residence abroad.

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49. Au Pair represent s t hat t he medical hist ory provided t o AuPairCare is t rue, and gives ful l consent t o release al l medical and psychiat ric hist ory informat ion t o pot ent ial host famil ies.

50. If Au Pair’s medical condition changes (including pregnancy), bet ween t he t ime of signing t his document and Au Pair’ s depart ure t o

t he U.S. , Au Pair underst ands t hat s/ he is required t o not ify AuPairCare and resubmit anot her Physician Verif ied Medical Hist ory document prior t o arrival . As wit h al l ot her t erms of t his Agreement , if Au Pair violat es t his t erm of t he Agreement , AuPairCare may in

it s sole discret ion t erminat e Au Pair’ s part icipat ion in t he program and immediat ely repat riat e Au Pair t o his/ her home count ry at Au Pair’ s expense.

51. Au Pair agrees t hat AuPairCare and/ or it s af f i l iat es or agent s may, wit hout l iabil it y or expense t o t hemselves, t ake what ever act ion t hey

deem appropriat e wit h regard t o Au Pair’ s healt h and safet y, including, but not l imit ed t o having Au Pair hospit al ized for medical services and t reat ment . Au Pair furt her agrees t hat if hospit al izat ion is not feasible for any reason, AuPairCare and/ or it s af f i l iat es or

agent s may rely upon t he advice and medical j udgment of local medical st af f in order t o make a decision as t o what is in Au Pair’ s best int erest s. Au Pair hereby gives ful l consent t o be medical ly t reat ed pursuant t o t he t erms of set fort h herein, and/ or t o undergo any t reat ment , including but not l imit ed t o surgery, which is det ermined t o be necessary t o Au Pair’ s healt h and wel l -being during Au Pair’ s

st ay abroad.

52. Insurance provided by AuPairCare is val id for 365 days f rom Au Pair’ s arrival in t he US and Au Pair accept s responsibil it y for payment of an ext ension fee t o receive any coverage af t er t he 365 days.

53. Au Pair accept s ful l responsibil it y for any medical expenses which are not covered by t he insurance pol icy provided by AuPairCare

t hrough a t hird part y.

54. In t he event Au Pair displays a serious medical condit ion t hat in t he j udgment of AuPairCare prevent s t he Au Pair f rom cont inuing in t he program (including but not l imit ed t o ment al i l lness, subst ance abuse, eat ing disorders and/ or pregnancy), whet her said condit ion is

pre-exist ing or new, Au Pair wil l be t erminat ed f rom t he au pair program at AuPairCare’ s sole discret ion.

H. Training and Education Requirements

55. Au Pair agrees t o complet e 32 hours of t raining prior t o arrival at Host Family home, as required by t he Unit ed St at es Depart ment of St at e. To meet t his requirement , Au Pair will attend in full the Au Pair Academy training program upon arrival in the United States

and complete a required Pre-Departure Project as def ined by AuPairCare.

56. Au Pair understands that all 12-month program Au Pairs are required to attend courses of study at an accredit ed U.S. post -secondary inst it ut ion for a minimum of six (6) credit hours or it s equivalent in credit hours. Host Family wil l provide Au Pair wit h t ime

of f and provide adequat e t ransport at ion t o and f rom t he place of inst ruct ion, and wil l pay t uit ion up t o a maximum of $500 per au pair per year. Local AuPairCare Area Direct ors are available t o provide informat ion about t his requirement and accept able schools;

however, it is Au Pair’ s responsibil it y t o plan appropriat ely so t hat s/ he is able t o ful f i l l t he requirement .

57. Au Pair underst ands t hat al l courses shal l be t aken at mut ual ly agreed upon t imes wit h t he Host Family. Au Pair shal l be responsible for cost s associat ed wit h such educat ional st udy t hat exceed t he amount paid by Host Family. Au Pair agrees t o submit an Educat ion Plan at t he st art of t he program year t o out l ine coursework plans. Au Pair agrees t o provide document at ion of coursework complet ion

t owards t he end of t he program year. In t he event Au Pair does not complet e t he educat ional requirement , Au Pair wil l be inel igible t o apply for an ext ension of t he au pair program.

I. Extension of Au Pair Program

58. Au Pair is hereby advised and underst ands t hat au pairs wishing t o part icipat e on t he Ext ension Program must submit t heir appl icat ion on or before AuPairCare’ s publ ished deadl ine dat e and AuPairCare does not guarant ee t hat AuPairCare or t he Depart ment of St at e wil l

approve any ext ension request or t hat au pairs who choose t o self -ext end wil l mat ch wit h a new Host Family.

59. Au Pair is hereby advised and underst ands t hat au pairs part icipat ing on t he ext ension program wil l receive an updat ed DS-2019 form t hat ref lect s t he 6, 9, or 12-mont h program ext ension. Al t hough au pairs wil l have a val id DS-2019 form, t he J-1 visa in his/ her passport

may have expired during t he f irst 12-mont hs of st ay in t he U.S. Any t ravel out side t he U.S. is at t he au pair’ s own risk, and AuPairCare cannot assist Au Pair or Host Family in resolving any visa concerns t hey may encount er.

60. Au Pair underst ands t hat Extension Au Pairs are required to repeat the educational component of t he program during t he ext ension t ime as fol lows: The educat ional component for a 6-mont h ext ension is not less t han t hree (3) semest er hours of academic credit or it s

equivalent . Host Family wil l cont ribut e up t o $250 t oward t he educat ional component . The educat ional component for a 9 and 12-mont h ext ension is not less t han six (6) semest er hours of academic credit or it s equivalent . Host Family wil l cont ribut e up t o $500

t oward t he educat ional component .

61. Au Pair is hereby advised t hat by ext ending t heir program t hey must complet e t he new program t erms in order t o be el igible for a ret urn f l ight home arranged by AuPairCare. In t he event t hat t he au pair chooses t o leave t he program early, he/ she wil l be responsible for

booking and paying for t heir own ret urn f l ight home.

J. Problem Resolution and Placement Changes

62. Au Pair is l iving as a member of a Host Family and is not under cont inual oversight or cont rol of AuPairCare st af f . Therefore, it is Au

Pair’ s responsibil i t y t o prompt ly advise AuPairCare of any signif icant problems or event s t hat occur during t he program, including but

not l imit ed t o Au Pair’ s healt h, safet y, welfare, or adj ust ment t o family, cult ure, or languages. For purposes of t his Agreement , a “ signif icant event or problem” is any change in Au Pair’ s circumst ance t hat may af fect an au pair’ s wel l -being and/ or l iving sit uat ion.

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63. Au Pair is hereby advised and underst ands t hat AuPairCare requires an initial adjustment period of 60 days following Au Pair’s arrival

before any placement change is considered; however, any decision regarding Au Pair removal is at AuPairCare’ s sole discret ion and

can be made at any t ime.

64. Au Pair should not ify t he local AuPairCare represent at ive of any misunderst andings or problems wit h t he Host Family if t hey persist af t er Au Pair has t ried t o address t hem wit h Host Family. AuPairCare wil l work wit h bot h Au Pair and Host Family t o at t empt t o resolve t he

problem before aut horizing a placement change. Au Pair must show a sustained good faith effort to resolve the issues with Host

Family before AuPairCare will approve an Au Pair’s request for a placement change. If Au Pair does not make a good fait h and

subst ant ial ef fort t o resolve t he problems or misunderst andings wit h Host Family, or if Au Pair violat es any t erms of t his Agreement , AuPairCare may in it s sole discret ion t erminat e t he Au Pair’ s part icipat ion in t he program and immediat ely repat riat e Au Pair t o his/ her

home count ry at Au Pair’ s expense.

65. Au Pair underst ands t hat t he nat ure of t he au pair program is one of f lexibil it y and cult ural exchange, and t hat placement changes may not be request ed in order t o achieve a preferred work schedule, locat ion, or perks provided by Host Family. Once Au Pair agrees t o mat ch wit h a Host Family, Au Pair has in ef fect agreed t o t hat Host Family’ s required schedule, locat ion and benef it s provided by t he

Host Family t o Au Pair. Au Pair agrees t o remain f lexible in order t o cont inual ly meet Host Family needs as t hey evolve over t he course of t he program year. Changes in Host Family needs do not constitute grounds for Au Pair to request a placement change.

66. In t he event Au Pair’ s f irst placement is not successful, and AuPairCare det ermines in it s sole j udgment t hat Au Pair shal l be placed in a

new family, Au Pair agrees to cooperate with AuPairCare during the entire re-matching process, including but not l imit ed t o ensuring t hat pot ent ial new Host Famil ies can easily reach Au Pair by e-mail and phone in a t imely manner t o arrange int erviews. Au Pair is

hereby advised and agrees t hat a replacement Host Family wil l be provided at t he sole discret ion of AuPairCare and may be dependent upon current Host Family availabil it y. A replacement Host Family may not be available. In t he event t hat AuPairCare is unable t o

provide a replacement Host Family wit hin 14 days f rom t he end of t he f irst placement , Au Pair’ s part icipat ion in t he program wil l end and Au Pair wil l have t o ret urn home at his/ her personal expense.

67. If t he Host Family is wil l ing to house Au Pair unt i l she or he is re-mat ched, and AuPairCare, in it s sole discret ion, det ermines t hat under

t he circumst ances it would be reasonable for Au Pair t o remain in t he home, but t he Au Pair refuses t o st ay wit h the family, Au Pair wil l

be required t o pay a $25.00 per day housing st ipend t o t he part y who houses him/ her, t ypical ly an AuPairCare f ield st af f member.

68. If Au Pair leaves the host family home wit hout not ice t o AuPairCare and/ or Host Family and does not cont act AuPairCare wit hin 24 hours f rom depart ure, Au Pair may be subj ect t o dismissal f rom t he program, and Au Pair may be immediat ely repat riat ed t o his/ her

home count ry at Au Pair’ s expense.

69. In t he event Au Pair does not successful ly complet e t heir f irst year program, and ext ension program, if appl icable, Au Pair is responsible for his/ her ret urn t ravel expenses.

70. AuPairCare is not responsible for any economic damage or loss al leged t o arise f rom loss of or unavailabil it y of a replacement Host

Family.

71. Au Pair agrees t hat any decision regarding an au pair’ s program st at us, dismissal, or re-placement wil l be made at t he sole discret ion of AuPairCare, and said decisions shal l be considered f inal .

72. In t he event of accident or serious i l lness or medical condit ion t hat , in t he j udgment of AuPairCare, prevent s Au Pair f rom cont inuing her/ his dut ies, she/ he wil l end t he program early and ret urn home.

K. Other Terms and Conditions

73. Au Pair agrees t o leave t he Unit ed Stat es wit hin 30 days of t he conclusion of his/ her program. Au Pair underst ands t hat any st ay beyond t he 30-day grace period is a direct breach of t he Regulat ions of t he Depart ment of St at e, and t hat Au Pair’ s fut ure abil it y t o t ravel ,

work or l ive in t he Unit ed St at es may be compromised.

74. Au Pair agrees not t o ent er int o any kind of cont ract ual agreement during t he program year in t he Unit ed St at es, including but not l imit ed t o business, employment , marit al or rel igious cont ract s.

75. Au Pair underst ands t hat if he/ she is t erminat ed or volunt arily leaves t he program for any reason, t hey are not el igible for t he 30-day

grace period benef it and must depart t he Unit ed St at es immediat ely.

76. Au Pair consent s and aut horizes AuPairCare t o use Au Pair’ s name, phot ographs, f i le, appl icat ion cont ent , video resume (video CV), or

video l ikeness of Au Pair or any comment s or st at ement s f rom host in mat erials or publ icat ions t o promot e t he AuPairCare program.

77. Au Pair underst ands t hat AuPairCare is not a part y t o any agreement bet ween Au Pair and t he Originat ing Exchange Organizat ion locat ed in Au Pair’ s home count ry (“ Originat ing Exchange Organizat ion” ). Au Pair acknowledges and agrees t hat t he Originat ing Exchange

Organizat ion is solely responsible t o Au Pair for inj ury or damage f rom a violat ion of any such agreement . AuPairCare assumes no dut ies or responsibil i t ies for any act s or omissions of t he Originat ing Exchange Organizat ion.

78. Au Pair agrees not t o post any Host Family personal informat ion, images or video onl ine or in publ icly accessible areas at any t ime,

including before, during or af t er durat ion of of f icial program year, wit hout t he Host Family’ s prior consent .

79. Au Pair underst ands t hat AuPairCare wil l make it s best , reasonable and dil igent ef fort s at locat ing and screening al l Host Famil ies. Au

Pair agrees t o assume t he risks involved in t he mat ching wit h a Host Family, and hereby irrevocably, uncondit ional ly, and ful ly waives,

releases and forever discharges AuPairCare, i t s subsidiaries, of f icers, employees, and/ or agent s f rom any and al l claims relat ed t o personal and/ or propert y damage, inj ury, loss, delay or expense incurred by Au Pair or any guest , employee or agent , due t o:

Page 6 of 6


(i) event s beyond AuPairCare’ s reasonable cont rol, including wit hout l imit at ion act s of God, act s of war or government act ions or

rest rict ions.

(i i) any event s and/ or act s direct ly or indirect ly caused by any int ent ional or negl igent act s or omissions at any t ime, in whole or in part ,

by any Au Pair and/ or Host Family or by any t hird part y, including but not l imit ed t o any member, guest , employee or agent of t he Host Family or ot her persons in t he host count ry, even if AuPairCare’ s negl igence is al leged t o have cont ribut ed t o t he event ,

(i i i) r isks associat ed wit h foreign t ravel and l iving abroad, including but not l imit ed t o risks associat ed wit h healt h care services, l iving condit ions, sanit at ion condit ions, road and t ransport at ion syst ems, criminal j ust ice syst ems, civil l ibert y laws, cust oms and values,

(iv) any dif ferences in t he l iving condit ions and st andards bet ween Au Pair’ s home and home count ry and t he host home and host count ry, and,

(v) any act or omission of t he Originat ing Exchange Organizat ion.

In t his respect , Au Pair acknowledges t hat neit her Host Family nor Au Pair are an employee or agent of AuPairCare and act ions or

omissions of Au Pair or Host Family are not t o be at t ribut ed in any way t o AuPairCare. Au Pair ful ly agrees t o assume al l such risks and agrees t o indemnify and hold harmless AuPairCare, it s subsidiaries, of f icers, employees and/ or agent s for any l iabil it y or expense,

including court cost s and legal fees incurred, t hat Au Pair has in any way caused or cont ribut ed t o, whet her direct ly or indirect ly, and whet her int ent ional ly or unint ent ionally.

80. This Agreement shal l be deemed t o have been made in t he St at e of Cal ifornia, U.S. , and it s val idit y, const ruct ion, breach, performance and int erpret at ion shal l be governed by t he laws of t he Stat e of Cal ifornia, U.S.

81. The part ies t o t he Agreement acknowledge and agree t hat any disput e or claim arising out of t his Agreement , including but not l imit ed

t o any result ing or relat ed t ransact ion or t he relat ionship of t he part ies, shal l be decided by neut ral , exclusive and binding arbit rat ion in San Francisco, Cal ifornia, U.S before an arbit rat ion provider select ed by AuPairCare, upon t he pet it ion of eit her part y.

In such proceeding, t he part ies may ut i l ize subpoenas and have discovery as provided in Cal ifornia Code of Civil Procedure Sect ions

1282.6, 1283 and 1283.05. The decision of t he arbit rat or shal l be f inal and binding and may be enforced in any court of compet ent j urisdict ion. Au Pair agrees t hat Cal ifornia is a fair and reasonable venue for resolut ion of any such disput e and it submit s t o j urisdict ion

of t he Court s of t he St at e of Cal ifornia because, among ot her reasons, t his agreement was negot iat ed in large part in Cal ifornia, and AuPairCare is domiciled in Cal ifornia.

In t he event t hat t he arbit rat ion clause is deemed void or inappl icable, each part y expressly consent s t o and submit s t o t he personal j urisdict ion of t he federal or st at e court (s) of San Francisco Count y, Cal ifornia, U.S. In any act ion, including arbit rat ion, brought for

breach of t his Agreement , t he prevail ing part y shall be ent it led t o recover reasonable at t orney’ s fees and cost s, including but not l imit ed t o t he cost s of arbit rat ion

82. If t here are any dif ferences bet ween this Agreement and any ot her program mat erials, t his Agreement shall cont rol. AuPairCare cannot

be legal ly bound or commit t ed by any person ot her t han a duly aut horized represent at ive. Part ies are required t o fol low t his Agreement and cannot vary f rom it s t erms.

83. An elect ronic or facsimile signat ure on t his Agreement shal l be considered t he same as an original .

ENTIRE AGREEMENT

Please read t he fol lowing st at ement s careful ly. Your signat ure below indicat es you have read and underst ood t hese st at ement s and t hat you agree t o t hem:

• I am capable of reading and underst anding t his Agreement in Engl ish

• I have had t he opport unit y t o ask quest ions and obt ain advice, t o ensure I underst and t his Agreement in it s ent iret y

• I accept t he t erms of t his ent ire Agreement and underst and t hat it is legal ly binding

• I do not rely on any promises, st at ement s or represent at ions t hat are not expressly st at ed in t his Agreement

• No al t erat ion of t he t erms of t his Agreement wil l be val id unless approved by AuPairCare in writ ing

• I have ret ained a copy of t his Agreement for my own records

Au Pair Ful l Name (Signat ure): ____________________________________________

Au Pair Ful l Name (Print ): ________________________________________________ Dat e : _______________________________

Mont h/ Day/ Year

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2014 Solicitud AuPairCare USA 0