11/10/2017 Au Pair Transition Au Pair Transition Please fill out this form with all of the applicable information. This form must be completed for all transitions prior to their entering the matching process. LCC name: * First Last LCC email address: * LCC phone number: * ### ### #### Your Program Director: * Please select your Program Director I have been an LCC for: * Less than 6 months More than 6 months Transition Information Who initiated the transition? * Host Family Au Pair Both Is this transition happening within the first month? * Yes No If yes, is the Program Director and/or Director of Customer Service aware of and has approved transition within the first month? Yes No Host Family USX Number: * Maximum Allowed: 32 characters.    Currently Used: 0 characters. Host Family Name: * https://culturalcare.wufoo.com/forms/au-pair-transition/ 1/5 11/10/2017 Au Pair Transition Maximum Allowed: 128 characters.    Currently Used: 0 characters. Host Familiy Phone Number: * ### ### #### Au Pair ID Number: * Maximum Allowed: 32 characters.    Currently Used: 0 characters. Au Pair Name: * Maximum Allowed: 128 characters.    Currently Used: 0 characters. Au Pair Cell Phone Number: ### ### #### Transition Category: * If Transition Category is "Other," please explain: Maximum Allowed: 384 characters.    Currently Used: 0 characters. Why is the au pair in transition? (Please provide your perspective). * Why is the au pair in transition? (Please provide the perspective of the au pair). * https://culturalcare.wufoo.com/forms/au-pair-transition/ 2/5 11/10/2017 Au Pair Transition Why is the au pair in transition? (Please provide the perspective of host family). * Where is the au pair staying? * Current Host Family Other Please provide complete contact information including the phone number. * Maximum Allowed: 255 characters.    Currently Used: 0 characters. Please describe the HF (location, # and ages of kids, at-home/single mom/dad, etc). * Maximum Allowed: 255 characters.    Currently Used: 0 characters. What gateway would the au pair use to transition to an alternate family. * Maximum Allowed: 32 characters.    Currently Used: 0 characters. Au Pair Information Describe the au pair (Please check all that apply) Smoker Has driving experience Cats OK Dogs OK Infant qualified Willing to care for infants in next family https://culturalcare.wufoo.com/forms/au-pair-transition/ 3/5 11/10/2017 Au Pair Transition If not mentioned previously, were there any issues with this au pair’s driving ability? Yes If yes, please explain if not already detailed previously. Maximum Allowed: 900 characters.    Currently Used: 0 characters. How much of the education component has the au pair completed? * Maximum Allowed: 32 characters.    Currently Used: 0 characters. Total amount spent on completed credits/hours towards educational component: * Maximum Allowed: 64 characters.    Currently Used: 0 characters. How much vacation has the au pair taken? * Maximum Allowed: 32 characters.    Currently Used: 0 characters. What is the English ability of the au pair? * Make a choice Who is recommending the au pair? * LCC Host Family Program Director No one If no one, why? Maximum Allowed: 512 characters.    Currently Used: 0 characters. https://culturalcare.wufoo.com/forms/au-pair-transition/ 4/5 11/10/2017 Au Pair Transition Who is recommending the host family? * LCC Au Pair Program Director No one If no one, why? Maximum Allowed: 512 characters.    Currently Used: 0 characters. Date of exit meeting: * / MM / DD YYYY Date the au pair must be placed by: * / MM / DD YYYY Last working day: * / MM / DD YYYY Special Remarks? https://culturalcare.wufoo.com/forms/au-pair-transition/ 5/5