Newborn Care Specialist

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Select Type of Care: 24-Hour Night Care Day Care
Requested Wages:
Nights: Days: 24-Hour:
Single: Twins: Triplets:
Personal Information
First Name: Last Name: Middle Initial:
Street Address:
City: State: Zip:
How long have you lived at your current address?
Date of Birth: Email Address:
Are you a legal citizen of the United States? YesNo
Please provide your phone number:
School City, State Major/Minor # of Years Degree

Describe any specialized education you've received in Newborn Care:

Describe any other related courses or training you have taken:

Do you have experience with special needs infants? Please describe:

Are you certified in CPR? YesNo Date of Expiration:
Are you certified in First Aid? YesNo Date of Expiration:
General Health Information
Do you smoke? YesNo Date of Last Physical:
Are you allergic to cats or dogs? Cats: Yes Dogs: Yes

Do you have any health problems that could interfere with your ability to be a childcare provider? If so, please explain:

Transportation and Background Information
Do you have your own vehicle? YesNo Drivers License #:
Make/Model of Vehicle: License Plate #:
Insurance Company: Expiration Date:

Have you been ticketed for any reason or had a traffic accident in the past 5 years?
If so, please explain:

Have you ever been convicted of a crime other than a minor traffic violation? YesNo
Have you ever been indicated as a perpetrator in a child abuse/neglect investigation? YesNo

If the answer to either or both of the above is yes, please explain:

Baby Nurse Positions
How many months or years experience do you have as a... Nanny? Baby Nurse?
How many Baby Nurse positions have you completed?
Additional Information
Do you have any visible body piercing or tattoos? NoYes
Are you available to travel out of state? NoYes
What languages are you fluent in?
What sleeping arrangement will you accept (i.e. in the baby's room, on the sofa, on the floor with a quilt, in a room of your own, etc.)?
What unique skills would you bring to a family as their Baby Nurse?
What do you find most rewarding about your work as a Newborn Specialist?
How would you best describe yourself? How do you like to spend your free time?
Tell us about your family background, where you grew up, what your family was like, your child care experience, why you want to be a Baby Nurse, and what is most important to you:
Please check the following areas you have had experience in, not including your own children:
Placing an infant on a feeding/sleeping schedule Umbilical Care
Caring for a colic infant Caring for a premature infant
Caring for an infant with refulx Caring for newborn triplets
Apnea Monitor Caring for newborn quadruplets
Heart Monitor Breastfeeding support
Gastrointestinal Tube Assisting with sibling interaction
Circumcision Care Older babies and toddlers sleep training
Employment History (Please list employment chronologically from present.)
Employer Name: Address:
Phone: Times to call:
Number of Children: Children's Ages:
Employed From: To:
May we contact this employer? YesNo To:

(If Yes, list phone number and contact name. If No, state reason.):

Positions Held:

Job Duties:

Reason for Departure:

What hours are you available for work?

Please indicate below the times you are available to work as well as your class schedule or any other regular events that would prevent you from working:

Week Day Class Schedule / Ongoing Commitments: Times Available for Work:
Applicant Signature: Date:
Agency Signature: Date:

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