Little Stars Forms Library

  • Little Stars Forms Library

    Please reach out to the Little Stars Director at lstars@meridiansvs.com or 763-458-0064 with any questions
  • Select role*

  • Thank you for your interest in Little Stars! This application is 15 pages, and will take an estimated 30-45 minutes to complete. 

    Helpful materials to gather before filling out the application:

    • Parent/Guardian Contact Information (Phone, email, physical address)
    • Parent/Guardian Driver’s License Information
    • Authorized Individuals and Emergency Contacts information (Phone, email, physical address)
    • Medical clinic and dental clinic information (Phone, fax, email, physical address)
    • Health insurance information
    • Immunization record(s)
    • Speciality health care provider information if completing an Individual Child Care Program Plan (ICCPP) for allergies (Phone, fax, email, physical address)

    Please note: You are not able to save and finish later. This application must be completed in full once it is started. 

  • If you need to submit a handwritten form, please visit the secure upload https://oriforms.jotform.com/231338605709963?jumpToPage=8 

  • Little Stars Initial Application

  • Date of Application*
     - -
  • Requested Start Date*
     - -
  • Rows
  • Child's Date of Birth*
     - -

  • Little Stars Parent/Guardian 1 Information

  • Child's Date of Birth*
     - -
  • Parent/Guardian 1 Relationship*
  • HIDE- Parent/Guardian 1 Relationship
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Is Parent/Guardian 1 an employee of Orion Associates, Meridian Services, Zenith Services, or Orion ISO?*
  • HIDE- Is Parent/Guardian 1 an employee of Orion Associates, Meridian Services, Zenith Services, or Orion ISO?

  • Parent/Guardian 2 Information

  • Parent/Guardian 2 Relationship*
  • HIDE- Parent/Guardian 2 Relationship
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Is Parent/Guardian 2 an employee of Orion Associates, Meridian Services, Zenith Services, or Orion ISO?*
  • HIDE- Is Parent/Guardian 2 an employee of Orion Associates, Meridian Services, Zenith Services, or Orion ISO?

  • Signatures

    I understand and accept that my electronic signature will be as valid as a handwritten signature and considered original to the extent allowed by applicable law. Please see the Consumer Consent Disclosure at https://www.jotform.com/consumer-consent-disclosure/
  • Clear
  • Date of Signature
     - -
  • I have reviewed the parent/guardian information for accuracy*

  • Little Stars Authorized Individuals

    List all individuals authorized to pick up your child
  • Child's Date of Birth*
     - -

  • Authorized Individual 1

  • Authorized Individual 1 Relationship*
  • HIDE- Authorized Individual 1 Relationship
  • Format: (000) 000-0000.

  • Authorized Individual 2

  • Authorized Individual 2 Relationship*
  • HIDE- Authorized Individual 2 Relationship
  • Format: (000) 000-0000.

  • Authorized Individual 3

  • Authorized Individual 3 Relationship*
  • HIDE- Authorized Individual 3 Relationship
  • Format: (000) 000-0000.

  • Unauthorized Individuals

  • Signatures

    I understand and accept that my electronic signature will be as valid as a handwritten signature and considered original to the extent allowed by applicable law. Please see the Consumer Consent Disclosure at https://www.jotform.com/consumer-consent-disclosure/
  • Clear
  • Date of Signature
     - -
  • I have reviewed the authorized individuals for accuracy*

  • Little Stars Emergency Contacts

    In the event of an emergency and the parents are unavailable, who should we contact?
  • Child's Date of Birth
     - -

  • Emergency Contact 1

  • Emergency Contact 1 Relationship*
  • HIDE- Emergency Contact 1 Relationship
  • Format: (000) 000-0000.

  • Emergency Contact 2

  • Emergency Contact 2 Relationship*
  • HIDE- Emergency Contact 2 Relationship
  • Format: (000) 000-0000.

  • Emergency Contact 3

  • Emergency Contact 3 Relationship*
  • HIDE- Emergency Contact 3 Relationship
  • Format: (000) 000-0000.

  • Signatures

    I understand and accept that my electronic signature will be as valid as a handwritten signature and considered original to the extent allowed by applicable law. Please see the Consumer Consent Disclosure at https://www.jotform.com/consumer-consent-disclosure/
  • Clear
  • Date of Signature
     - -
  • I have reviewed the emergency contacts for accuracy*

  • Little Stars Health Care Information

  • Child's Date of Birth*
     - -

  • Medical

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Dental

    If the child does not have a dentist, please list the parent/guardian's dentist
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Hospital

  • In the event of an emergency, is there a preferred hospital the child should be routed to?*
  • HIDE- In the event of an emergency, is there a preferred hospital the child should be routed to?
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Insurance Information

  • Is the child covered by health insurance?*
  • HIDE- Is the child covered by health insurance?
  • Format: (000) 000-0000.
  • Is there secondary health insurance coverage?*
  • HIDE- Is there secondary health insurance coverage?
  • Format: (000) 000-0000.

  • Signatures

    I understand and accept that my electronic signature will be as valid as a handwritten signature and considered original to the extent allowed by applicable law. Please see the Consumer Consent Disclosure at https://www.jotform.com/consumer-consent-disclosure/
  • Clear
  • Date of Signature
     - -
  • I have reviewed the health care information form for accuracy*

  • Little Stars Medical Records Acknowledgement

  • Child's Date of Birth*
     - -

  • Child care centers in Minnesota are required to engage the services of a Nurse/Health Consultant to review health policies and procedures and children’s records. My signature confirms my consent for review of my child’s records by the nurse/health consultant.

  • Are your child's immunizations up to date?*
  • HIDE- Are your child's immunizations up to date?
  • Browse Files
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  • Are you concerned that your child may be prone to any type of allergies?*
  • HIDE- Are you concerned that your child may be prone to any type of allergies?
  • Does your child have any medical conditions which I should be made aware of?*
  • HIDE- Does your child have any medical conditions which I should be made aware of?

  • Signatures

    I understand and accept that my electronic signature will be as valid as a handwritten signature and considered original to the extent allowed by applicable law. Please see the Consumer Consent Disclosure at https://www.jotform.com/consumer-consent-disclosure/
  • Clear
  • Date of Signature
     - -
  • I have reviewed the medical records acknowledgement for accuracy*

  • Little Stars Secure Upload

  • Is the form you are uploading an Little Stars Initial Deposit and Credit Card Authorization Form?*
  • Format: (000) 000-0000.
  • Child Date of Birth*
     - -
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof

  • Little Stars Medical Policies Acknowledgement

  • Child's Date of Birth*
     - -

  • Individual state child care licensing regulations regarding medication must be followed. Any mandatory state form regarding administration of prescription or non-prescription medication must also be completed and signed by a parent/guardian.

    If permitted by state child care licensing regulations, I authorize Little Stars staff to administer to my child topical non-prescription medications as needed, according to the dosage instructions on the medication container.

    For any other medication, if permitted by state child care licensing regulations or center policy, I will provide written authorization for Little Stars staff to administer the medication in accordance with written instructions from the child’s health care professional or me, as required. I will complete necessary authorization forms with my signature and understand prescription label dosage instructions must be followed. I will provide the medication in its original container with the pharmacist’s label. I agree to provide any such medications, as these will not be provided by the center.

    • 1. I understand that I will be asked to provide the center with updated immunization information for my child. If I wish to request a religious or medical exemption to Little Star's practice of securing immunization information, I understand my request must meet state child care licensing regulations.
    • 2. I may be asked to provide additional medical information as required by state child care licensing regulations. I understand that my failure to provide this information may result in a suspension of services.
    • 3. I agree to promptly provide information to the center regarding any conditions, illnesses, allergies, or other special needs that may require specific care or attention and agree to provide additional documentation as needed.
    • 4. If the center staff notifies me that my child is ill, I must pick up my child as soon as possible and no later than one (1) hour after being contacted.
    • 5. If my child contracts a reportable contagious disease, my child may return only with a physician/health care professional’s note indicating that my child is no longer contagious.
    • 6. In case of a medical or other emergency while my child is under the center’s supervision, I understand that center staff will attempt to contact me immediately; however, in the event that I cannot be reached, or when a delay may further jeopardize my child’s health, I hereby authorize center staff to act on my behalf and to take the emergency measures including those listed below if deemed necessary by center staff or by medical authorities for the care and protection of my child. I authorize Little Stars to:
      • Consult the physician or dentist named on the previous page if I cannot be reached. Administer first aid and/or cardiopulmonary resuscitation.
      • Transport my child via ambulance or other emergency medical service to a local hospital or other urgent care facility, if deemed necessary by paramedics, police, or other emergency personnel.
      • Obtain any emergency medical or dental treatment deemed necessary by medical authorities.
      • Transport my child to a local emergency shelter in the event of an emergency evacuation of the center.
    • 7. If I wish to request a religious or personal exemption to Little Star’s practice of securing necessary emergency medical treatment, I understand state child care licensing authorities must be consulted to determine if such an exemption may be granted.
  • I have read and understand this agreement*
  • HIDE- I have read and understand this agreement

  • Signatures

    I understand and accept that my electronic signature will be as valid as a handwritten signature and considered original to the extent allowed by applicable law. Please see the Consumer Consent Disclosure at https://www.jotform.com/consumer-consent-disclosure/
  • Clear
  • Date of Signature
     - -
  • I have reviewed the medical policies acknowledgement for accuracy*

  • Financial Information and Little Stars Hours of Operation

  • Child's Date of Birth*
     - -

  • The center is open from 7:30 a.m. to 6:00 p.m., Monday-Friday. Little Stars will be closed in recognition of the following holidays: New Year’s Day, Memorial Day, Fourth of July, Labor Day, Thanksgiving Day, Christmas Day. The center’s hours and holiday schedule may vary and may be changed at any time. In addition to holiday closures, we dedicate time every year for employees’ professional development and training. Please see your Center Director for information on when your center will be closed for these training days. Tuition is not reduced as a result of center closures.

    If I or other authorized persons fail to pick up my child and/or contact the center, and I or other authorized persons cannot be reached, center staff, within thirty minutes after closing time or in accordance with state child care licensing regulations, may release children to the custody of child protective services or other local authorities.

    The center will be open whenever possible on a regularly scheduled day, during normal hours. The procedure for notifying families should severe weather or other conditions prevent the center from opening on time or at all will be posted. If it becomes necessary to close early, it will be my responsibility to arrange for my child’s early pick-up. I agree to notify the center staff by 7:00 am when my child is absent. All enrolled children must have a schedule.

    All enrolled children must check in and out on the computer every day. 

    • Full-time: Full-time enrollment reserves your child’s space during any or all of our scheduled hours of operation.
    • Part-time: Part-time enrollment allows your child to attend full days, but fewer than five days a week. If your family chooses the part-time enrollment option, we require that you commit to a weekly schedule so that we may arrange for appropriate staffing and supplies. If your child is enrolled part-time, and his/her scheduled day falls on a Little Stars holiday or he/she is ill, tuition is not discounted for that week. Your child may attend an alternate day only if an additional day of care has been charged to your tuition account.
    • Half-days: Little Stars Academy may offer half-day enrollment options when classroom occupancy allows. Our half-day program entitles your child up to four consecutive hours of care each day. If your family needs more than four child care hours on a particular day, you will be charged a full day for additional care.

    Acknowledgements:

    • 1. I will promptly update any information provided for in this Agreement if such information changes.
    • 2. I consent to Little Stars communicating with me by telephone, text, e-mail, or other means. Written communication may be sent home with emergency contact and release persons when necessary.
    • 3. I understand that in an effort to maintain the professional status of center staff and prevent any potential conflict of interest, babysitting by center staff members is discouraged. However, should I hire any center staff members, it must be outside the center premises and with the understanding that such arrangements and payment for services are solely between me and the center staff member. The center and Little Stars do not sanction the arrangements, and I agree to hold Little Stars harmless from any such arrangement.
    • 4. State child care licensing regulations are on file at the center and are available for review upon request. Certain state child care licensing regulations have requirements in addition to those contained in this Agreement.
    • 5. A child may be dis-enrolled by Little Stars without prior notice if, in the sole opinion of Little Stars, it is in the best interest of the child or Little Stars.
    • 6. Little Stars reserves the right to alter its policies and program at any time. Center management does not have the authority to alter or modify the terms of this Agreement (other than inserting information where required) either verbally or in writing.
    • 7. The terms of this Agreement, including the tuition and fees, are subject to change in whole or in part by the center with 30 days notice. This Agreement may be terminated by the center at any time
  • I have read and understand this agreement*
  • HIDE- I have read and understand this agreement

  • Signatures

    I understand and accept that my electronic signature will be as valid as a handwritten signature and considered original to the extent allowed by applicable law. Please see the Consumer Consent Disclosure at https://www.jotform.com/consumer-consent-disclosure/
  • Clear
  • Date of Signature
     - -
  • I have reviewed the financial information and hours of operation form for accuracy*

  • Little Stars Parent/Guardian Authorizations

  • Child's Date of Birth*
     - -

  • Signatures

    I understand and accept that my electronic signature will be as valid as a handwritten signature and considered original to the extent allowed by applicable law. Please see the Consumer Consent Disclosure at https://www.jotform.com/consumer-consent-disclosure/
  • Clear
  • Date of Signature
     - -
  • I have reviewed the authorizations for accuracy*

  • Little Stars Grievance Form

  • Child's Date of Birth
     - -

  • A grievance is a complaint about something you do not like about where your child's services are being rendered. 

    What can you expect of the grievance process? 

    When you begin services, you will be given a copy of this policy. You should feel free to file a grievance without being afraid of losing the placement of your child. These policies and procedures will be updated on an annual basis and reviewed with you. 

    How can you file a grievance? 

    Step 1- Talk to the teacher about your complaint or problem right away. Let the teacher know you want to help with the grievance. The teacher should help you with the grievance within two (2) to five (5) days. 

    Step 2- If you do not think the teacher was able to help you with your grievance, then you should contact the Program Director. The Program Director will help you with the grievance within two (2) to five (5) days. 

    Step 3- If you did not think the Program Director was able to help you with your grievance, then you should contact the Chief Administrative Officer, Stephen Hage via phone (763-2450-5004) or email (shage@orionassoc.net). The Chief Administrative Officer will help you with the grievance within two (2) to five (5) days and formally respond in writing. 

    If you have any concerns, complaints, or would like any further explanation about the licensing rule that you feel have not been answered by our staff, you can contact the Minnesota Department of Human Services (DHS) Division of Licensing at 651-296-3971.

     

  • Signatures

    I understand and accept that my electronic signature will be as valid as a handwritten signature and considered original to the extent allowed by applicable law. Please see the Consumer Consent Disclosure at https://www.jotform.com/consumer-consent-disclosure/
  • Clear
  • Date of Signature
     - -
  • I have reviewed the grievance form for accuracy*

  • Little Stars External Preparations Form

  • Child's Date of Birth*
     - -
  • I hereby give Little Stars permission to apply one or more of the following external preparations, in accordance with the directions for use on the container*
  • HIDE- I hereby give Little Stars permission to apply one or more of the following external preparations, in accordance with the directions for use on the container

  • Signatures

    I understand and accept that my electronic signature will be as valid as a handwritten signature and considered original to the extent allowed by applicable law. Please see the Consumer Consent Disclosure at https://www.jotform.com/consumer-consent-disclosure/
  • Clear
  • Date of Signature
     - -
  • I have reviewed the external preparations form for accuracy*

  • Little Stars Handbook Review Acknowledgement

  • Child Date of Birth*
     - -

  • The Little Stars Program Services Parent Handbook and Policies https://oriforms.jotform.com/231035604084043 is to be reviewed by the parent/guardian upon enrollment, and each year annually. 

  • I have received Little Stars Program Services Parent Handbook and Policies https://oriforms.jotform.com/231035604084043. Revisions to policies have been reviewed and I understand any questions I may have may be directed to Little Star’s Director. 

  • I have read and understand this agreement*
  • HIDE- I have read and understand this agreement

  • Signatures

    I understand and accept that my electronic signature will be as valid as a handwritten signature and considered original to the extent allowed by applicable law. Please see the Consumer Consent Disclosure at https://www.jotform.com/consumer-consent-disclosure/
  • Clear
  • Date of Signature
     - -
  • I have reviewed the handbook acknowledgement form for accuracy*

  • Little Stars Personal Resume

  • Child's Date of Birth*
     - -

  • Demographic Information

  • Rows
  • Are there pets in the household?*
  • HIDE- Are there pets in the household?

  • Social Development

  • Select the items your child knows*
  • HIDE- Select the items your child knows

  • Emotional Development

  • Does your child separate easily from you?*
  • HIDE- Does your child separate easily from you?
  • Is your child afraid of anything?*
  • HIDE- Is your child afraid of anything?
  • Does your child have a favorite toy, blanket, or soother?
  • HIDE- Does your child have a favorite toy, blanket, or soother?
  • Does your child spend time with other children?*
  • HIDE- Does your child spend time with other children?

  • Nutrition Information

  • Does your child have any food sensitivities?*
  • HIDE- Does your child have any food sensitivities?
  • Is your child currently breast fed?*
  • HIDE- Is your child currently breast fed?
  • HIDE- Is your child currently breast fed?
  • Is your child bottle fed? (Includes bottled breast milk)*
  • HIDE- Is your child bottle fed? (Includes bottled breast milk)
  • Rows
  • Has your child been introduced to solids?*
  • HIDE- Has your child been introduced to solids?
  • Select what your child eats with*
  • HIDE- Select what your child eats with
  • Which solids has your child been introduced to?*
  • HIDE- Which solids has your child been introduced to?

  • Self-Care Information

  • Does your child need any help with dressing?*
  • HIDE- Does your child need any help with dressing?
  • Is your child in diapers?*
  • HIDE- Is your child in diapers?
  • Is your child prone to diaper rash?*
  • HIDE- Is your child prone to diaper rash?
  • Is your child toilet trained?*
  • HIDE- Is your child toilet trained?
  • Has toilet training begun?*
  • HIDE- Has toilet training begun?
  • Does your child require assistance using the toilet*
  • HIDE- Does your child require assistance using the toilet

  • Medical History

  • Did your child have any difficulties with speech?*
  • HIDE- Did your child have any difficulties with speech?
  • Select the common childhood illnesses that your child has had*
  • HIDE- Select the common childhood illnesses that your child has had
  • Has your child had any of these diseases?*
  • HIDE- Has your child had any of these diseases?
  • Does your child have any speech, hearing or visual problems?*
  • HIDE- Does your child have any speech, hearing or visual problems?
  • Has your child ever had any surgeries or do they have any prosthetic limbs etc.?*
  • HIDE- Has your child ever had any surgeries or do they have any prosthetic limbs etc.?
  • Does your child have any restrictions to play or activities?*
  • HIDE- Does your child have any restrictions to play or activities?
  • Does your child have any sensitivities to any objects/items?*
  • HIDE- Does your child have any sensitivities to any objects/items?
  • Does your child have any allergies?*
  • HIDE- Does your child have any allergies?

  • If yes, an Individual Child Care Program Plan (ICCPP) For Allergies will need to be completed prior to first day of attendance. 

  • Signatures

    I understand and accept that my electronic signature will be as valid as a handwritten signature and considered original to the extent allowed by applicable law. Please see the Consumer Consent Disclosure at https://www.jotform.com/consumer-consent-disclosure/
  • Clear
  • Date of Signature
     - -
  • I have reviewed the personal resume for accuracy*

  • Little Stars Individual Child Care Program Plan (ICCPP) For Allergies

  • Child's Date of Birth*
     - -

  • Parent/Guardian Information

    Call 911 whenever Epinephrine has been administered. Only after 911 has been called, staff should call the Program Director so they may contact the parent. State that an allergic reaction has been treated and additional epinephrine may be needed. Stay with the child.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Health Care Provider Information

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Authorization is hereby given to the child care provider to obtain emergency medical care or treatment in the event of an emergency*
  • HIDE- Authorization is hereby given to the child care provider to obtain emergency medical care or treatment in the event of an emergency
  • If the providers listed above are unavailable, I authorize another licensed physician to treat my child*
  • HIDE- If the providers listed above are unavailable, I authorize another licensed physician to treat my child

  • Specific Allergy Action Plan

  • Is the child asthmatic?*
  • HIDE- Is the child asthmatic?
  • Specify the actions that need to be taken by staff*
  • HIDE- Specify the actions that need to be taken by staff
  • Specify the actions that need to be taken by the parent/guardian*
  • HIDE- Specify the actions that need to be taken by the parent/guardian

  • Signatures

    I understand and accept that my electronic signature will be as valid as a handwritten signature and considered original to the extent allowed by applicable law. Please see the Consumer Consent Disclosure at https://www.jotform.com/consumer-consent-disclosure/
  • Clear
  • Date of Signature
     - -
  • I have reviewed the ICCPP for accuracy*

  • Little Stars Initial Deposit and Credit Card Authorization Form

  • Thank you for choosing to have your child explore and learn with us. We are excited to have you and your child as part of our group! 

    Complete an Initial Deposit and Credit Card Authorization Form. Please follow the steps below: 

    • Step 1- Hover over the PDF below. Click the Printer icon to print the form
    • Step 2- Fill out all of the fields on the form 
    • Step 3- Upload the completed form to the Secure Upload here https://oriforms.jotform.com/231338605709963?jumpToPage=8 

    Please reach out to the Little Stars Director at lstars@meridiansvs.com or 763-458-0064 with any questions. 

  • Parent and Child Information

  • Format: (000) 000-0000.
  • #Select the number of children enrolled at Little Stars

  • Payment Information

  • Authorizations

  • Clear
  • #Date of Signature
     - -
  • Clear
  • #Date of Signature
     - -

  • Next Steps

  • A copy of the completed packet will be sent to the email of the signing parent/guardian. 

    Please contact lstars@meridiansvs.com with any questions. 

  • I have reviewed the initial enrollment application for accuracy*
  • Should be Empty: