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Provider Application
First name
*
Last name
*
Email
*
Phone
*
Position
Role(s) you are applying for (check all that apply)
*
Postpartum Doula
Newborn Care Specialist
Sleep Consultant
Lactation Support/IBCLC
Mental Health Professional
Registered Nurse (Women and Infant/NICU Experience)
LNA
Nanny
Household Manager
Other
Years of experience:
*
CPR/First Aid Certified?
*
Yes
No
CPR/First Aid Expiration Date?
Month
Month
Day
Year
Relevant Certifications (list & include expiration date)
Do you have a current LLC or business license?
*
Yes
No
Do you carry Professional Liability Insurance (CMF or equivalent)?
*
Yes
No
Are you open to working as:
*
Independent Contractor
Referral Partner
Agency Staff
Service area you cover (cities/states)
*
Type of services you offer?
*
Availability (check all that apply)
*
Days
Nights
Weekends
On-call/Emergencies
About You: Tell us a little about your philosophy of care and why you'd like to join the Night Owl team.
*
Hourly Rate Range (or packaged rates)
*
Please upload or attach: Resume or CV, Copies of certifications/licenses, and Proof of insurance ( CMF etc.)
Upload File
Link to CV/LinkedIn
Submit
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