PLEASE NOTE: AS OF OCTOBER 1, 2008 EXCLUSIVELY BABY NURSES WILL HIRE ONLY CERTIFIED NCS'S, CERTIFIED THROUGH THE NCSA
Check out the requirements for being placed as a Newborn Care Specialist with this agency.
Please fill out the application after you have completed
the application,
1. Use your edit button and select "select all"
then go back to edit and select "copy"
2. Open your Word program
and go to the edit button and select "paste" and the entire application will
come up in your Word Program.
3. Go to 'File" & select "save as"
and save the file in 'MY DOCUMENTS' as "(your name), EBN application " ie: Smith, Silvia EBN application.
4. Go to your email hit the "attachment" or attach file button, browse will come up, go to My Documents
and find the fil
5. Highlight the file and it click open, that will put
it in your email and then send to: nancy@exclusivelybabynurses.com do not fax. This information
must be kept in the computer.
Last Name 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?
Schooling
information
Baby Nurse Education:
Dates
Institution
City
State
Last Grade
Completed
Area of Study
Degree
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
Jobs –
Please attach
resume if applicable
(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
t 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:
Check what
you have experience in:Based
on past Baby Nurse Assignments ONLY, not your own children,
please cheWeas 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:
Personal
Information:
Health InforPmation
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:
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.
Explain your method of
sleep training and what age to can train by.
10. Describe
how you would give a newborn a bath?
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.
PERSONAL ESSAY
26. Write
a short bio on yourself, your hobbies, interests, family life and why you
became a Baby Nurse or Newborn Care Specialist.