Host Family Information Request Form

 Click here for the Information Request Form for Au Pairs

The form below is for U.S. families that would like information on hosting an au pair.  If you live outside of the U.S. click here for information on Becoming an Au Pair in the U.S.  If you are a U.S. citizen who would like to become an au pair in another country, visit our Working Abroad Au Pair program.

Host Family Information Request Form

Complete the information on this page and we will send you our brochure, an application packet, and keep you up to date on Au Pair USA events in your area and any special offers or services.

Fields marked with an asterisk (*) are required.

We are new applicants or reapplying:*	-Select One-New ApplicantsReapplying
If re-applying: Our last au pair is leaving / has left as of (mm/dd/yyyy):	Month "---010203040506070809101112 Day ---01020304050607080910111213141516171819202122232425262728293031Year: Year 2003 2004 2005 2006 2007
When would you prefer your Au Pair to arrive?*	Please Select MonthJanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember
Host Mother's First Name:
Host Father's First Name:
Host Family Last Name:*
Street Address: *
City: *
State: *	--Select One--AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict Of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming
Zip Code: *
Email: *
Home Phone: *
Mother's Work Phone:
Father's Work Phone:
Where did you first hear about Au Pair USA?	-Select One-Ad in Parenting/Child Care PublicationCurrent Au Pair/Host FamilyFriend / FamilyHost Family Referral ProgramInternational Au Pair AssociationLocal CoordinatorLocal NewspaperOnline SearchPostcard/MailingPre-Match with New Au PairRe-Applying Host FamilyYellow PagesOther
Please explain. Online search words, website, name of local representative, where you saw an ad or a poster, or where you picked up a brochure.
Any additional questions or comments?