Cultural Care Au Pair

Are you a... *
Host family or au pair ID number (if you know it)
Your name * First Last
Name of child First Last
Child's birthdate MM / DD / YYYY
Name of child First Last
Child's birthdate MM / DD / YYYY
Name of child First Last
Child's birthdate MM / DD / YYYY
Name of child First Last
Child's birthdate MM / DD / YYYY
Phone * ### - ### - ####
Email *
What do you want to tell us? *
Upload a photo
Upload a photo
Upload a photo
Upload a photo
Upload a photo
Approval information
For good and valuable consideration, the receipt and sufficiency of which is hereby acknowledged, I, for myself (and on behalf of my minor children listed above, if applicable), consent to the unrestricted use of my name and likeness gathered by representatives of International Care Ltd., a Swiss company, Cultural Care, Inc., a Massachusetts company and their affiliates, employees, officers and agents (together referred to as “Cultural Care Au Pair”) in interviews given by me (by phone, in person, or in writing) as well as the use of my photograph(s) or video(s) to be used for public relations, news articles or broadcasts, education, advertising, inclusion on Web sites, social media or promotional materials. I understand that all such materials will become the property of Cultural Care Au Pair.

I release Cultural Care Au Pair and those acting under their authority from any liability connected with the taking, recording, or publication of said interviews, photographs, videotapes, or sound recordings.

I waive any right to inspect or approve any writing, photo or video taken or used by Cultural Care Au Pair.

This agreement constitutes the sole, complete and exclusive agreement between Cultural Care Au Pair and me regarding the interviews and images and I am not relying on any other representation whether oral or written. *
Yes, I consent to the use of my photograph(s) and/or video(s).
Do Not Fill This Out

Cultural Care Au Pair

Approval information