Baby Nurse Directory Client Application

602-412-8497 Business

602-283-5465 Fax

Please fill out the form completely. After we receive your information and the non refundable $50 we will send the information you send us to the available Newborn Care Specialist's. They will respond with their interest. We will then email you the names and phone numbers of each of the respondents. There should be a minimum of 3 unless this is a last minute request or unless you are in an area we have limited coverage. We recommend you begin with a phone interview. PLEASE REMEMBER YOU DO ALL THE BACKGROUND AND REFERENCE CHECKING. The Baby Nurse Directory is not responsible for the quality of the Baby Nurse or Newborn Care Specialist you hire. We are only a directory not an agency. If you wish to hire an agency that will do all the background and reference checking and find the Newborn Care Specialist for you please try Exclusively Baby Nurses.

Mother's Last Name:
Mother's First Name
Place of Employment
Father's First Name
Father's Last Name
Place of Employment
Work Phone
Home Phone
Cell Phone
Email Address:
Address Where the Newborn Care Specialist Will Work
City
State
Zip Code
Are you having:	Single baby Twins Triplets Quads
If you are pregnant now what is your expected due date
Are you having a planned C-Section?	Yes No
I would like a Newborn Care Specialist to start on what date?
How long are you expecting to need a Newborn Care Specialist
Do you require a RN?
If yes, why
If this is a night position where will the Newborn Care Specialist rest?	Guest Room Guest House Baby's Room Couch Air Mattress
Is this a a night awake job (The Newborn Care Specialist is not allowed to sleep on the job)? If so your hourly charge will be more.	Yes No
Fee's for a Newborn Care Specialist start at $18 -$25 for a single baby, $20 - $35 twins and $23 - $45 twins. Your price will depend on location, experience of the NCS, and number of babies. What are you willing to pay your Newborn Care Specialist
I am interested in a Newborn Care Specialist working these days/nights	Sunday Monday Tuesday Wednesday Thursday Friday Saturday
I am interested in:	Days Nights 24/7
If you need to explain hours and days please use this space to do so
Please give us the following information if your baby/ies have been born or if you know the information already. DOB, GENDER, NAME, WEIGHT
I will be:	Breast feeding Bottle feeding Pumping and bottle feeding Breast and bottle feeding Breast feeding days and bottle feeding nights
Was your baby premature?	Yes No
If yes, please state how premature
Does your child have medical issues that would require additional knowledge?	Yes No Other
Is your child on:	Apnea Monitor Feeding Tube Medications Other
If you answered 'other' to one of the two medical questions, please use this space to explain
Does your child suffer from Reflux	Yes No I am not sure
Are there pets in the home? If so please state what type and how many.
Please list the names and ages of other siblings in the home. Please be aware that the Newborn Care Specialist cares only for the newborn. The siblings are the responsiblity of the parent
Is there smoking in the home?	Yes No We smoke outside
Please add anything you feel is important for us to know concerning you and your family that would make a difference in hiring a Newborn Care Specialist for you.
I understand there is a one time non refundable finders fee for the Baby Nurse or Newborn Care Specialist of $50. This will be paid on the Thank you page. Please type your name as acknowlegement of this fee. NOTE: This fee will not be charge if there are no Newborn Care Specialist available at the time of your application. We will simply send you an email stating 'no one is available at this time'
Please do the background and reference check for me and send me the results $350 this will include the $50 non refundable fee (this check will only be done on the one (1)Baby Nurse you hire) This check will include: State and Federal criminal check, SS check, address, drivers license and nationwide sex offenders, reference verification. Please type your name in the following box if this is the way you would like to find your Newborn Care Specialist

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You will find the Pay Pal button on the Thank You page which you should be connected to as soon as you submit this form. Thank you.

If you have questions please feel free to call the office at 602-412-8497