Parent Application Parent(s) Name(s): * Address Address Address Address Address Address State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Address Primary Phone: * Email Address: * Parent(s) Profession(s): * Place(s) 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 Have your infant(s) arrived or expecting? * ArrivedExpecting How many infant(s) would you like care for? * Single ChildTwinsTripletsQuadruplets Child's Name When was your child born? How much does your child weigh? How many ounces a day is your child eating? Second Child's Name When was your second child born? How much does your second child weigh? How many ounces a day is your second child eating? Third Child's Name When was your third child born? How much does your third child weigh? How many ounces a day is your third child eating? Fourth Child's Name When was your fourth child born? How much does your fourth child weigh? How many ounces a day is your fourth child eating? Do your children have allergies, acid reflux, any other special care? YesNo Does your child have allergies, acid reflux, any other special care? YesNo Please explain: Child's Name When is the child's due date? Second Child's Name When is the second child's due date? Third Child's Name When is the third child's due date? Fourth Child's Name When is the fourth child's due date? Are you looking for night time child care for your child/children? YesNo Are you looking for special needs child care? YesNo Neighbor/Closest Family Member * Medications?: * YesNo 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? YesNo 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? When are you looking to start care? At this time, do you plan on: * BreastfeedingFormula feedingBoth Will you also be using a breast pump for bottle feeding? YesNo Approximate length of service needed: * Less than 2 weeks2 to 4 weeks8 to 12 weeksUntil sleeping through the nightOther Other Approximate hours per week: * Who referred you to Night Owl Nanny Care LLC? * reCAPTCHA If you are human, leave this field blank. Submit
