Please read the following guidelines:

1. This may take an hour or more to fill out. Be prepared to fill out this application in its entirety.
2. Please be as thorough as possible in each section. A potential family will receive parts of this application and we want them to feel like they know a little bit about you on paper before they speak to you on the phone or in person.
3. Make sure you have all phone numbers for references available to include in your application. If you send it in without, your application will be sent back to you to "re-do".
4. When filling in your answers in a text box, DO NOT hit your 'Enter' or 'Return' keys. Just type as your text will wrap automatically.

Thank you for inquiring with All About Baby Nurses. We are excited for you to become part of our organization!


If you prefer to fill this out in Microsoft Word and email it to us, please download the application and email it to us at nancy@exclusivelybabynurses.com.

Primary Information:
Last Name: First Name: Middle:
Any Other
Known Names: 		Home Address:
City: State: Zip Code:
What are your major cross streets?
Phone: Home Phone: Cellular Phone: Pager
Social Security Number: Are you eligible to work in the United States?
Which states are you willing to work in? Put "All" if you can work anywhere in America. Email
Address:


Placement Preferences:
Type of position you are seeking (check as many that apply):
24 Hour Care  Nights Only  Days Only 
Hourly Rate Days:
Single: Twins: Triplets: 		Hourly Rate Nights:
Single: Twins: Triplets:
What do you charge for 24 hour care? Maximum # of babies you would care for?
 
What experience do you have working with newborns?
Multiples Experience? (check all that apply): Twins  Triplets  Quads 
Age of children:
 
Please check additional tasks that you are willing to do (KEEPING IN MIND THAT THE CHILDREN ARE ALWAYS YOUR FIRST PRIORITY):
Laundry       Light Housekeeping   Errands        
Cooking       Dishes (loading and unloading dishwasher)
 
How did you get your first baby nurse job:
Have you ever been (or are you currently) a licensed child care provider?
       In what state(s)?
Have you ever had a child care license suspended or revoked? If so, please explain:
Have you ever been convicted of a crime?  
( A conviction will not necessarily disqualify an applicant from employment.) (For purposes of this question, “convicted” includes a plea of guilty, nolo contendre, no contest, or similar plea, participation in a pre-trial diversion or deferred entry of judgment program even if the program was completed and charges were dismissed, bail forfeiture, or verdict or finding of guilt.). If “Yes,” please explain:
Are you CURRENT on your infant/child CPR certification? Expiration Date:
In case of emergency, please contact:   Phone:

Personal and Family Background (Optional):
Who do you live with (alone, parent(s), roommate, boyfriend, etc)
Any marriage plans?
Father's Name: Mother's Name:
Father's Business Phone: Mother's Business Phone:
Number and ages of brothers and sisters in your family
Religion? Do you need any time off to attend religious services? If yes, when?
Do you smoke? Would you work in a smoking environment? Yes  No
Do you have any allergies? If yes, to what?
Any dietary restrictions? If yes, to what?
Any visible body piercing or tattoos? If yes, explain?
Do you speak a foreign language? If yes, which ones(s)?
Are you: Single  Married  Divorced  Widowed  Separated 
What is your maiden name?


Indicate Your Interests Below:
Music: Very MuchSome-WhatNot At All
Computers: Very MuchSome-WhatNot At All
Writing: Very MuchSome-WhatNot At All
Sewing: Very MuchSome-WhatNot At All
Movies: Very MuchSome-WhatNot At All
Rollerblading:Very MuchSome-WhatNot At All
Sports: Very MuchSome-WhatNot At All
Piano:Very MuchSome-WhatNot At All
Art: Very MuchSome-WhatNot At All
Reading:Very MuchSome-WhatNot At All
Shopping: Very MuchSome-WhatNot At All
Swimming:Very MuchSome-WhatNot At All
Skiing: Very MuchSome-WhatNot At All
TV:Very MuchSome-WhatNot At All


Baby Nurse Education:
DatesInstitutionCityStateLast Grade
Completed		 Area of StudyDegree
High School:
College:
College:
Trade School :
Other Courses:
Are you a Registered Nurse (RN)?
Are you a Licensed Practical Nurse (LPN)?
Have you taken any Baby Nurse classes?

Baby Nurse Assignments (Please list most recent first -phone numbers are required
for us to conduct a reference check):
Start/End Dates Family Name Cellular Phone # Home Phone #
1.
Duration of Assignment :
Did you recieve a letter of recommendation from this family? Yes  No
2.
Duration of Assignment :
Did you recieve a letter of recommendation from this family? Yes  No
3.
Duration of Assignment :
Did you recieve a letter of recommendation from this family? Yes  No
4.
Duration of Assignment :
Did you recieve a letter of recommendation from this family? Yes  No
5.
Duration of Assignment :
Did you recieve a letter of recommendation from this family? Yes  No
6.
Duration of Assignment :
Did you recieve a letter of recommendation from this family? Yes  No
7.
Duration of Assignment :
Did you recieve a letter of recommendation from this family? Yes  No

Permanent Child Care Experience (Please list most recent first - if you have nanny
experience please list below. DO NOT include babysitting in this section):
Start/End Dates Family Name Cellular Phone # Home Phone # # of Kids / Ages
1.
Reason for leaving:
Did you recieve a letter of recommendation from this family? Yes  No 		Gross Salary:
2.
Reason for leaving:
Did you recieve a letter of recommendation from this family? Yes  No 		Gross Salary:
3.
Reason for leaving:
Did you recieve a letter of recommendation from this family? Yes  No 		Gross Salary:


Based on past Baby Nurse Assignments ONLY, not your own children,
please check the following areas you have experience in:
Circumcision Care Caring for premature infants Umbilical cord care
Sibling Interaction Caring for newborn twins Caring for newborn triplets
Breastfeeding support Caring for a colic infant Sleep Training
Feeding Tube Apnea Monitor Other Medical Devices
3. Other, please explain:


Health Information
Do you have any physical restrictions? Yes  No
If yes, please explain:
Are you currently under a physician's care? Yes  No
If yes, please explain:
Have you ever suffered from any kind of substance abuse? Yes  No
If yes, please explain:
When was your last physical? Date:    Were there any problems? Yes  No
If yes, please explain:


BABY NURSE WRITTEN INTERVIEW

Please make sure that you allow yourself 1 to 2 hours of time to fully complete the following questions. 
This information will be given to potential clients to learn more about who "you" are and what you know. 
If you give a one or two sentence answer the client may not learn much about you.  Please be as
detailed as possible.  One or two paragraphs would be great for each answer.  Clients would rather
read too much than not enough.
1. What did you like most about your mother/father’s parenting skills?
2. What qualities would you look for if you were hiring a baby nurse?
3. What do you see as your personality strengths?
4. What do you see as your personality weaknesses?
5. Describe your personality:
6. Describe your relationship with your family:
7. What qualities/characteristics are needed to be a successful baby nurse of multiples?
8. What experience do you have working with preemies (singles or multiples)?
9. How many weeks should a newborn be before giving a full bath?
10. Describe how you would give a newborn a bath?
11. How would you care for the following newborn’s body parts?
Cradle Cap: 
Fingernails:
Umbilical Cord Stump:
Circumcised Penis:

Uncircumcised Penis:

Vaginal Area:
12. Describe how you would care for a baby with colic:
13. Describe how you would care for a baby with reflux:
14. Describe how you would care for a baby that is premature:
15. What are the different ways you would soothe a crying newborn?
16. Describe any experience you have with a special needs newborn:
17. What kind of emotional support would you give to the parents of a newborn?
18. Under what circumstances would you call the baby’s doctor?
19. Describe how you would handle a two year olds interruptions with the newborn:
20. How comfortable are you working with new parents that want you to follow the schedule they have set up versus suggesting your own?
21. Have you ever felt agitated during a baby nurse position and if so, how did you calm yourself?
22. How do you deal with the lack of sleep on a baby nurse job?
23. How do you deal with the stress in your life?
24. What books have you read to educate yourself on newborns, preemies, multiples, special needs, etc.

PERSONAL ESSAY
25. Why do you feel you are a good baby nurse? Please include special skills, and training about yourself.


To the best of my knowledge, the information on this application is true. I understand that misrepresentation or omission of facts in connection with the information provided may be sufficient cause for dismissal wherever discovered. I permit All About Baby Nurses to show this application and all references to parents as a part of the evaluation process.

I understand that the information on this application has been requested for the purpose of evaluating my qualifications for employment by a family, as a child care provider. I also understand that I am not, and will not be an employee of All About Baby Nurses.

I have read and understand the terms and conditions as listed above.