Get a Nanny Parent Application Form Parent Application Parent(s) Name(s): * Address Address Address Address Address Address State/Province Alabama Alaska Arkansas Arizona California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Address Mobile Phone: * Email Address: * Parent Profession: * Place of Employment: * Parent Profession: Place of Employment: What services are you looking for? (select all that apply) * Night Nanny Sleep Training Daytime doula Special Needs Care Birth Doula Sleep Training Online How much does your baby weigh? How many ounces a day is your baby eating? How old is your baby or toddler? * Are you expecting? Single Twins Triplets Quadruplets When is/was the due date? Are you looking for night time child care for your child/children? Yes No Are you looking for special needs child care? Yes No Neighbor/Closest Family Member * Medications?: * Yes No Please list types of medications: * How and when to give medications: * Toileting: * Eating * Bathing behaviors/activities: Bedtime behaviors/habits. Does she/he awaken often? Leave the room/stay in the room?: Is your child on the Autism Spectrum? Yes No Cognitive abilities: Verbal abilities. Do you use pictures/signs/I should know?: Social interactions: Physical limitations: Environmental (sensitivity to light, sound touch, etc.): Restrictive interests: Repetitive interests: Words or actions that calm: Words or actions that cause distress: How should I handle meltdowns?: Please describe the unique, individual qualities of your child that will help in providing loving, enjoyable, optimal care. What are their favorite books, music or interests? Favorite activities and play? Games? Does she/he like to hear singing? Is it okay to go outside? Anything else I should know? Does your child have allergies, acid reflux, any other special care? Yes No Please explain When are you looking to start care? Child's name * Date of Birth * Child's name Date of Birth Child's name Date of Birth Child's name Date of Birth At this time, do you plan on: * Breastfeeding Formula feeding Both Will you also be using a breast pump for bottle feeding? Yes No Approximate length of service needed: * Less than 2 weeks 2 to 4 weeks 8 to 12 weeks Until sleeping through the night Other Other Approximate hours per week: Who referred you to Night Owl Nanny Care LLC? reCAPTCHA Submit If you are human, leave this field blank.