Au Pair Completion Form

We at Au Pair International would like to thank you for your participation in the Au Pair Program and hope that you found it a rewarding and fulfilling experience.

In order to consider your program successfully completed we ask that you complete the following information no later than 45 days prior to the end of your program year:

Monthly Meetings and Contacts (for the dates of your program)
Request for Return Flight Information
13th-Month Insurance Request
Program Feedback

Note that failure to return all documentation on time will result in a $250 late fee.

Personal Information

First Name

Last Name

Home Country

Your Arrival Date to the U.S.:

Your email

Au Pair Phone Number

Host Family Name

Host Family State of Residence

Area Director Name

Monthly Meetings and Contacts
Please check the box next to each month you attended a meeting and/or had other contact with your Area Director (or alternate person in Area Directors absence, e.g. Regional Director). In addition, indicate if this contact was an in-person meeting or a contact via phone/email.

January Contact:In-PersonMeeting (Virtual or Live)Email or PhoneNo Contact

February Contact:In-Person Meeting (Virtual or Live)Email or PhoneNo Contact

March Contact:In-Person Meeting (Virtual or Live)Email or PhoneNo Contact

April Contact:In-Person Meeting (Virtual or Live)Email or PhoneNo Contact

May Contact:In-Person Meeting (Virtual or Live)Email or PhoneNo Contact

June Contact:In-Person Meeting (Virtual or Live)Email or PhoneNo Contact

July Contact:In-Person Meeting (Virtual or Live)Email or PhoneNo Contact

August ContactIn-Person Meeting (Virtual or Live)Email or PhoneNo Contact

September Contact:In-Person Meeting (Virtual or Live)Email or PhoneNo Contact

October Contact:In-Person Meeting (Virtual or Live)Email or PhoneNo Contact

November Contact:In-Person Meeting (Virtual or Live)Email or PhoneNo Contact

December Contact:In-Person Meeting (Virtual or Live)Email or PhoneNo Contact

Regulations and Responsibilities

I confirm that I have fulfilled my duties in my host family during the au pair program, followed the program rules and regulations, and that I am not leaving any unsettled matters (such as phone bills, money owed, etc.) behind with my host family.

I have completed my Educational Requirement and I have returned the Proof of Education form to my Regional Director.
YesNo

If ready, please attach a copy of your Education Documentation here:

Requesting Your Return Flight
US Department of State Regulations require au pairs to depart from the USA no later than 30 days after the end of their program year. Please discuss options for your return flight with your host family before completing the information below.

I am requesting a return flight homeI will make my own arrangements back to my home country (Au Pair International will not reimburse you for these expenses)I am declining my return flight home

Preferred Departure City:

Preferred Home Country Arrival City:

Preferred Departure Dates (Please list at least 5 dates):

Departure Date:

* Flights are booked from your host family’s departure airport to the airport that you originally departed from. There may be an extra fee if you request a different departure/arrival city.
** Au Pair International does not guarantee that we can book a flight for the day or airport that is requested, however, we will do our best to honor those requests. Remember, we only fly into and out of major international airports. Once a flight is booked it cannot be changed.

Insurance Extension Options

As an au pair you are covered by a limited insurance policy during your participation in the Au Pair Program, which is valid for a period of 12 months. If you plan to stay in the U.S. for your 13th month, it is recommended that you purchase additional insurance coverage as you will no longer be covered under the original API Insurance policy.

Au Pair International does offer the option to extend your insurance coverage under your current insurance plan, at your own cost. Should you wish to extend the insurance please indicate below:

"13th Month" Insurance Policy Plan (Cost of Plan)
Note that only au pairs currently enrolled in the "Premium Insurance Plan" are eligible to continue with the Premium plan for their 13th month.

Basic Insurance Plan ($75)Premium Insurance Plan ($95)I decline additional insurance coverage (No Cost)

Satisfaction Survey

What did you enjoy most about your experience in the Au Pair Program?

Would you recommend becoming an au pair to your friends/family?
YesNo

How would you recommend that we improve the program for future au pairs?

After returning home for a period of 2 years you will be eligible to come back to the United States as an au pair (if you are under the age of 27). Would you be interested in receiving information about returning to the program after this 2 year period?
YesNo

Would you be interested in learning more about being an Ambassador for Au Pair International in
your home country?
YesNo

I confirm that the information contained within this form is both accurate and complete.

Au Pair Signature:

Date Signed:

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