New Parent Application

Client Information --------------------------------------------------------------------------------------------------------------------------------------

Mother's Full Name *

Spouse's Full Name

Mom's Age *

Select your area *

If you don't see your area, shoot us a message.

Street Address *

City *

State *

Country *

Postal code *

Phone *

Email *

Primary contact for time with Rested? -------------------------------------------------------------------------------------------------------

Primary Contact's Full Name *

Spouse's Phone Number *

Spouse's Email *

How many babies are you having? *

One baby

Twins

Triplets

Where are you planning to deliver?

Who is your physician, midwife, or doula?

Is this your first baby? *

Yes

No

If not, what are the names & ages of your other children?

Has your family previously worked with an infant care specialist? *

Yes

No

If yes, what company did you work with?

Do you anticipate returning to work after the baby is born? *

Yes

No

If yes, how long is your maternity leave?

Will your partner be at home after the baby is born? *

How many nights are you planning to use Rested? *

What specific nights are you interested in each week? *

Do you prefer a 9 hour (not available for four nights per week) or 10 hour shift? *

How many weeks do you plan to work with Rested? *

When would you like to start with Rested? *

Does your family have any food allergies?

Baby Information ---------------------------------------------------------------------------------------------------------------------------------------

Is the baby already here? *

Yes

No

Expected Due Date

Baby's Name

Do you plan to breastfeed? *

Pediatrician *

If Baby is Already Here -------------------------------------------------------------------------------------------------------------------------------

Has your family taken the Covid vaccine? *

Yes

No

Baby's Birth Date

Baby's Birth Weight

Baby's Current Weight

Parking and/or Gate Code Instructions *

Do you have any pets? *

Yes

No

What type? Name?

Are you enrolled in a Carrot fertility/family benefits program through your employer that provides reimbursement for postpartum support services like nighttime infant care? *

Double check with your employer - your family fertility benefits may cover our nighttime infant care services!

Please list any questions that we can answer for you?

How did you find out about Rested? *

Collect Payment - Please choose $475 if you have lived in New York or New Jersey previously

$ 375

$ 475