Mother's First Name

Mother's Last name

Mother's Place of employment

Work Phone

Father's Last Name

Father's First Name

Father's Place of Employment

Work Phone

Home Phone

Email Address:

Home Address

City

State

Zip Code

Major Cross Streets

We charge no application fee to search for your Newborn Care Specialist. You pay nothing until you hire someone. Please choose how long you will be requiring a Newborn Care Specialist/Baby Nurse. The following are agency fees: $30 per day, $100 per week, $350 per month, $650 2 months, $800 3 months. Please select the one closest to what you are desiring.

Are you having:

If you are still pregnant what is your approximate due date?

Are you having a scheduled C- Section?

If so, the date

What date would you like a Newborn Care Specialist to begin?

Do you require a registered nurse, RN, for this position?

If you answered yes, could you be more specific as to why you need a RN. Please be aware that an RN will charge you considerably more than a Newborn Care Specialist. RN's are usually hired in cases where medical assistance will be required. This does not include apnea monitors and feeding tubes as a Newborn Care Specialist can handle these issues.

If you answered yes, could you be more specific as to why you need a RN. Please be aware that an RN will charge you considerably more than a Newborn Care Specialist. RN's are usually hired in cases where medical assistance will be required. This does not include apnea monitors and feeding tubes as a Newborn Care Specialist can handle these issues.

Do you wish to interview before hand, if this is not a last minute request?

If so where should the profiles be emailed to?

If this is a night position, what are the resting arrangements for the Newborn Care Specialist?

Newborn Care Specialist set their own rates. Variations are as follows: Single baby: $22 - $30 hour Twins: $25 - $35 hour Triplets $27 - $45 hour 24 hour rates range from $350 up What do you wish to pay your Newborn Care Specialist. Please keep in mind that the more experienced ladies will be the ones charging more.

I am interested in a Newborn Care Specialist for the following evening/night schedule. Newborn Care Specialists generally do a Sunday - Thursday night schedule 10 PM - 6 AM, however they will work whatever schedule works for you. Please be specific. This will help the Newborn Care Specialist determine if she will be available.

I am interested in a Newborn Care Specialist for the following day time schedule. Please be specific. This will help the Newborn Care Specialist determine if she will be available.

Please describe your newborn/newborns. If they have already been born or if you know sex and names, please include date of birth, sex, name and weight.

Was your baby (ies) born premature?

If premature..how many weeks at birth?

Is your child on:

If other please describe.

Are you planning on:

Does your baby suffer from:

Is your baby on medications? If so which ones?

Are there any pets in the household?

If yes please describe the pets and how many?

Are there any siblings in the household?

If the answer was yes, how many and what ages. Please remember the Newborn Care Specialist job is to care for the newborn only.

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.

Submit button following agreement

Exclusively Baby Nurses, Client Agreement and Release :

This Understanding and Release is entered into between Exclusively Baby Nurses and the person filling out this application

1. The parties agree and acknowledge that any temporary caregiver hired by Client will be an employee of Client, and not an employee of Exclusively Baby Nurses. Client shall be responsible for verification of the temporary caregiver's eligibility for employment in the United States as provided by the Immigration and Naturalization Services Form I-9. Client shall independently verify all information pertinent to Client's decision to hire or retain the temporary caregiver. Client understands and acknowledges that Exclusively Baby Nurses will use reasonable efforts to provide background information from reliable agencies about each temporary caregiver candidate; however, Client shall be responsible for ensuring the accuracy of the information each temporary caregiver candidate provides.

2. Client shall, at Client's sole cost and expense, indemnify Exclusively Baby Nurses, and its members, employees and agents for, from and against all liabilities, claims and damages (whether known or unknown) arising from or related to Client's negotiation or employment of any temporary caregiver. To the fullest extent permitted by law, Client knowingly waive all claims, causes of action and damages (whether known or unknown) against Exclusively Baby Nurses arising from or related to Client's negotiation or employment of any temporary caregiver, or any act or omission of any temporary caregiver.

3. Client understands that newborn specialists hired through Exclusively Baby Nurses are not employees of Exclusively Baby Nurses. Client understands that client may be responsible for withholding and filing employment taxes for each calendar year in which the caregiver's payments exceed the limits set forth in the Internal Revenue Code.

4. Referral of Newborn Specialist/Baby Nurse to Third Parties or Subsequent Re-employment of Newborn Specialist/Baby Nurse. Employer agrees that if a Newborn Specialist/Baby Nurse is hired through Exclusively Baby Nurses, Employer shall be prohibited from recommending that Newborn Specialist/Baby Nurse to other third parties to provide Newborn Specialist/Baby Nurse services to those third parties or from re-employing that Newborn Specialist/Baby Nurse outside of the Agency for a period of Three (3) years after termination of the Newborn Specialist/Baby Nurse's employment with Employer . Employer agrees and understands that a referral by

Employer to any third party of a Newborn Specialist/Baby Nurse or the re-employment of a Newborn Specialist/Baby Nurse that has been provided to Employer by Exclusively Baby Nurses is harmful and damaging to the interests of Exclusively Baby Nurses. As such Employer agrees that if Employer refers an Exclusively Baby Nurses Newborn Specialist/Baby Nurse to a third party or rehires a former Newborn Specialist/Baby Nurse, Exclusively Baby Nurses shall be entitled to damages equal to the amount of placement fees that Exclusively Baby Nurses would have earned for that placement.

5. Client acknowledges there will be a charge to their credit card for every Newborn Care Specialist visit. The agency fee is $ 30 day,$100 week, $350 one month, $650 two months or $800 three months. Any extension of services beyond this contract will be automatically deducted using the credit card provided by the client. The refusal to pay for an extension of services will result in the Newborn Care Specialist being withdrawn from the job immediately.

6. Client agrees that all forms and paperwork distributed to Client for their use is the property of Exclusively Baby Nurses. Client agrees to not copy or distribute materials without the written consent of Exclusively Baby Nurses.

7. Exclusively Baby Nurses agrees to disclose all relevant information acquired by Exclusively Baby Nurses throughout the qualification process including but not limited to background investigations. Parents acknowledge that Exclusively Baby Nurses uses a third party investigation agency, and neither EXCLUSIVELY BABY NURSES NOR THE INVESTIGATORS CAN FULLY ENSURE THAT THE BACKGROUND INFORMATION AND OTHER RECORDS USED BY EXCLUSIVELY BABY NURSES, ARE ACCURATE OR COMPLETE INFORMATION ABOUT A PARTICULAR CAREGIVER . Exclusively Baby Nurses encourages Client to thoroughly review the background information and to interview the potential Newborn Specialist/Baby Nurse candidates to further determine their suitability. Exclusively Baby Nurses makes no representations or warranties regarding the background information received with regard to the particular caregivers.

8. Not all of the caregivers that are referred by Exclusively Baby Nurses are registered nurses. The term “Nurses” used in the Exclusively Baby Nurses does not refer to registered nurses, however is intended to mean a person who takes care of a child or children as defined in The Random House College Dictionary Revised Edition. While some of the caregivers may actually be registered nurses some are not registered nurses. Client understands that he or she has the option of requesting that the caregiver referred through Exclusively Baby Nurses may be a registered nurse practitioner, however Client also understands that the hourly rate may be more than that of a caregiver that is not a registered nurse.

9. Client agrees to pay the newborn specialist directly for services rendered.

I have read and understand the terms of this Understanding and Release.

Your submittal of this form is your agreement with the terms of this agreement. Thank you for your time.