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CAREGIVER APPLICATION
First Name
Last Name
Email
Phone
Street Address
City
State
Alabama
Alaska
Arizona
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California
Colorado
Connecticut
Delaware
District of Columbia
Florida
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Hawaii
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Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
ZIP
Willing to Commute
10 miles
25 miles
50 miles
75 miles
100+miles
Eligible to work in the U.S?
Yes
No
Years of Experience
LinkedIn Profile URL
Your Specialties
Newborn Care Specialist (NCS)
Postpartum Doula
Sleep Consultant
Lactation Consultant (IBCLC)
Educated Career Nanny
Executive Housekeeper
Private Chef
Personal Assistant
Language 1
English
Spanish
French
Mandarin
German
Italian
Portuguese
Russian
Arabic
Hindi
Tagalog
Polish
Other
Proficiency
Native
Fluent
Conversational
Basic
Language 2
English
Spanish
French
Mandarin
German
Italian
Portuguese
Russian
Arabic
Hindi
Tagalog
Polish
Other
Proficiency
Native
Fluent
Conversational
Basic
Language 3
English
Spanish
French
Mandarin
German
Italian
Portuguese
Russian
Arabic
Hindi
Tagalog
Polish
Other
Proficiency
Native
Fluent
Conversational
Basic
Other Languages - Please Specify
Availability 1 - Start Time
12:00 AM
12:30 AM
1:00 AM
1:30 AM
2:00 AM
2:30 AM
3:00 AM
3:30 AM
4:00 AM
4:30 AM
5:00 AM
5:30 AM
6:00 AM
6:30 AM
7:00 AM
7:30 AM
8:00 AM
8:30 AM
9:00 AM
9:30 AM
10:00 AM
10:30 AM
11:00 AM
11:30 AM
12:00 PM
12:30 PM
1:00 PM
1:30 PM
2:00 PM
2:30 PM
3:00 PM
3:30 PM
4:00 PM
4:30 PM
5:00 PM
5:30 PM
6:00 PM
6:30 PM
7:00 PM
7:30 PM
8:00 PM
8:30 PM
9:00 PM
9:30 PM
10:00 PM
10:30 PM
11:00 PM
11:30 PM
Availability 1 - End Time
12:00 AM
12:30 AM
1:00 AM
1:30 AM
2:00 AM
2:30 AM
3:00 AM
3:30 AM
4:00 AM
4:30 AM
5:00 AM
5:30 AM
6:00 AM
6:30 AM
7:00 AM
7:30 AM
8:00 AM
8:30 AM
9:00 AM
9:30 AM
10:00 AM
10:30 AM
11:00 AM
11:30 AM
12:00 PM
12:30 PM
1:00 PM
1:30 PM
2:00 PM
2:30 PM
3:00 PM
3:30 PM
4:00 PM
4:30 PM
5:00 PM
5:30 PM
6:00 PM
6:30 PM
7:00 PM
7:30 PM
8:00 PM
8:30 PM
9:00 PM
9:30 PM
10:00 PM
10:30 PM
11:00 PM
11:30 PM
Availability 1 - Days
Sun
Mon
Tue
Wed
Thu
Fri
Sat
Availability 2 - Start Time
12:00 AM
12:30 AM
1:00 AM
1:30 AM
2:00 AM
2:30 AM
3:00 AM
3:30 AM
4:00 AM
4:30 AM
5:00 AM
5:30 AM
6:00 AM
6:30 AM
7:00 AM
7:30 AM
8:00 AM
8:30 AM
9:00 AM
9:30 AM
10:00 AM
10:30 AM
11:00 AM
11:30 AM
12:00 PM
12:30 PM
1:00 PM
1:30 PM
2:00 PM
2:30 PM
3:00 PM
3:30 PM
4:00 PM
4:30 PM
5:00 PM
5:30 PM
6:00 PM
6:30 PM
7:00 PM
7:30 PM
8:00 PM
8:30 PM
9:00 PM
9:30 PM
10:00 PM
10:30 PM
11:00 PM
11:30 PM
Availability 2 - End Time
12:00 AM
12:30 AM
1:00 AM
1:30 AM
2:00 AM
2:30 AM
3:00 AM
3:30 AM
4:00 AM
4:30 AM
5:00 AM
5:30 AM
6:00 AM
6:30 AM
7:00 AM
7:30 AM
8:00 AM
8:30 AM
9:00 AM
9:30 AM
10:00 AM
10:30 AM
11:00 AM
11:30 AM
12:00 PM
12:30 PM
1:00 PM
1:30 PM
2:00 PM
2:30 PM
3:00 PM
3:30 PM
4:00 PM
4:30 PM
5:00 PM
5:30 PM
6:00 PM
6:30 PM
7:00 PM
7:30 PM
8:00 PM
8:30 PM
9:00 PM
9:30 PM
10:00 PM
10:30 PM
11:00 PM
11:30 PM
Availability 2 - Days
Sun
Mon
Tue
Wed
Thu
Fri
Sat
Availability 3 - Start Time
12:00 AM
12:30 AM
1:00 AM
1:30 AM
2:00 AM
2:30 AM
3:00 AM
3:30 AM
4:00 AM
4:30 AM
5:00 AM
5:30 AM
6:00 AM
6:30 AM
7:00 AM
7:30 AM
8:00 AM
8:30 AM
9:00 AM
9:30 AM
10:00 AM
10:30 AM
11:00 AM
11:30 AM
12:00 PM
12:30 PM
1:00 PM
1:30 PM
2:00 PM
2:30 PM
3:00 PM
3:30 PM
4:00 PM
4:30 PM
5:00 PM
5:30 PM
6:00 PM
6:30 PM
7:00 PM
7:30 PM
8:00 PM
8:30 PM
9:00 PM
9:30 PM
10:00 PM
10:30 PM
11:00 PM
11:30 PM
Availability 3 - End Time
12:00 AM
12:30 AM
1:00 AM
1:30 AM
2:00 AM
2:30 AM
3:00 AM
3:30 AM
4:00 AM
4:30 AM
5:00 AM
5:30 AM
6:00 AM
6:30 AM
7:00 AM
7:30 AM
8:00 AM
8:30 AM
9:00 AM
9:30 AM
10:00 AM
10:30 AM
11:00 AM
11:30 AM
12:00 PM
12:30 PM
1:00 PM
1:30 PM
2:00 PM
2:30 PM
3:00 PM
3:30 PM
4:00 PM
4:30 PM
5:00 PM
5:30 PM
6:00 PM
6:30 PM
7:00 PM
7:30 PM
8:00 PM
8:30 PM
9:00 PM
9:30 PM
10:00 PM
10:30 PM
11:00 PM
11:30 PM
Availability 3 - Days
Sun
Mon
Tue
Wed
Thu
Fri
Sat
Engagement Types
Live-in only
Live-out only
Either live-in or live-out
Rotational
Contract
Short-term
Fill-in
Willing to Travel?
Yes, domestic
Yes, international
No
Valid Passport
Yes
No
Available From
Have you cared for twins
Yes — multiple families
Yes — one family
No, but I'm open to twin placements
No
Have you cared for triplets or higher-order multiples?
Yes — multiple families
Yes — one family
No, but I'm open to multiple placements
No
Have you cared for infants in the NICU or immediately post-NICU discharge?
Yes — in a NICU setting
Yes — post-discharge in the home
Both
No
Have you cared for infants with reflux, colic, or feeding difficulties?
Yes — extensively
Yes — some experience
No
Are you certified in infant/child/adult CPR and First Aid
Yes - current
Yes - expired
No
Which certifying body issued your CPR/First Aid certification?
CPR/First Aid certification expiration date
Do you Carry Professional liability Insurance
Yes - Current
Yes - expired
No
Liability Insurance expiration date
Do you have NICU experience?
Yes
No
If Yes, in what Capacity?
NICU Nurse
NICU Doula
NICU-experienced NCS
Day rate -1 baby (desired starting rate)
Overnight rate - 1 baby (if different from day rate)
Day rate-twins
Overnight rate twins (if different from day rate)
Day rate triplets or more
Overnight rate triplets or more
Tell us about yourself and your approach to newborn and family care
Introduction Video Link (optional)
Vaccination status (select all Current)
Flu shot
TDAP
MMR
COVID-19
None of the above
Some families require caregivers to have certain vaccinations. Are you willing to provide proof of, or obtain, vaccinations if a placing family requires it?
Yes, I'm willing to meet a family's vaccination requirements
Willing to discuss depending on the requirement
No
Highest Level of education completed
High school diploma
Associate degree (2-year)
Bachelor's degree (4-year)
Master's degree
Doctorate (PhD, MD, DO)
Trade or vocational program
Other
School/institution name
Field of study or major
Year completed (or expected)
Brief career background (before or alongside caregiving)
Certifying / member organizations (select all that apply)
ProDoula
CAPPA
NCSA (Newborn Care Specialist Association)
DONA International
Newborn Care Solutions
Other
Membership/certification ID number(s) — as registered with the organization
Name your credentials are registered under (if different from your legal name)
Years of experience as a Postpartum Doula
Years of experience as a Nanny/childcare
Reference 1 - Full Name
Reference 1 - Relationship to you
Reference 1 - Phone
Reference 1 - Email
Reference 1- Type of care you provided
Reference 1 - Baby's age when you started
Reference 1 - OK to contact?
Yes
Not yet, please ask me first
Reference 2 - Full Name
Reference 2- Relationship to you
Reference 2- Phone
Reference 2 - Email
Reference 2- Type of care you Provided
Reference 2 - Baby's age when you started
Reference 2- OK to Contact?
Yes,
Not yet,
please ask me first.
Reference 3 - Full Name
Reference 3 - Relationship to you
Reference 3 - Phone
Reference 3 - Email
Reference 3 - Type of care you provided
Reference 3 - Baby's age when you started
Reference 3 - OK to contact?
Yes,
Not yet,
Please ask me first
Send
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