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*

I need to fill out an initial enrollment packetI need to print a packet
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
Click the print icon in the top right corner to print

Little Stars Initial Application
Applicant Name (this is the person applying, not the child)*

First NameLast Name
Applicant Email*
example@example.com
Date of Application*

MonthDayYear
Date
Requested Start Date*

MonthDayYear
Date

Days and Times Requested*

	Hours Requested	Drop Off Time	Pick Up Time
Monday
Tuesday
Wednesday
Thursday
Friday

Child Name*

First NameLast Name
Please list any nicknames that your child has
Child's Date of Birth*

MonthDayYear
Date
Child Age*
Child Primary Language*
Please list any allergies the child has

Little Stars Secure Upload
Is the form you are uploading an Little Stars Initial Deposit and Credit Card Authorization Form?*

YesNo
Parent/Guardian Name*

First NameLast Name
Parent/Guardian Email*
example@example.com
Parent/Guardian Phone Number*
Please enter a valid phone number.
Child Name*

First NameLast Name
Child Date of Birth*

MonthDayYear
Date
Secure file upload*

Cancelof

Little Stars Medical Policies Acknowledgement
Child Name*

First NameLast Name
Child's Date of Birth*

MonthDayYear
Date
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*

YesNo
HIDE- I have read and understand this agreement

YesNo
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/
Signing Parent/Guardian Name*

First NameLast Name
Signing Parent/Guardian Email*
example@example.com
Parent/Guardian Signature*

Clear
Date of Signature

MonthDayYear
Date
I have reviewed the medical policies acknowledgement for accuracy*

YesNo

Financial Information and Little Stars Hours of Operation
Child Name*

First NameLast Name
Child's Date of Birth*

MonthDayYear
Date
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*

YesNo
HIDE- I have read and understand this agreement

YesNo
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/
Signing Parent/Guardian Name*

First NameLast Name
Signing Parent/Guardian Email*
example@example.com
Parent/Guardian Signature*

Clear
Date of Signature

MonthDayYear
Date
I have reviewed the financial information and hours of operation form for accuracy*

YesNo

Little Stars Parent/Guardian Authorizations
Child Name*

First NameLast Name
Child's Date of Birth*

MonthDayYear
Date
HIDE-Walking Trips: I give permission for my child to leave the center for outdoor exercise and educational purposes, with the understanding that my child will be accompanied by center staff and under proper staff supervision at all times. (If required by individual state child care licensing regulations, I will be given a specific permission slip for each walking trip.)
Walking Trips: I give permission for my child to leave the center for outdoor exercise and educational purposes, with the understanding that my child will be accompanied by center staff and under proper staff supervision at all times. (If required by individual state child care licensing regulations, I will be given a specific permission slip for each walking trip.)*
HIDE- Water Activities: I give permission for Little Stars to include my child in supervised water activities, including water activities at the center. I will be given a specific permission slip for all off-site water activities. Water activities will meet state child care licensing regulations.
Water Activities: I give permission for Little Stars to include my child in supervised water activities, including water activities at the center. I will be given a specific permission slip for all off-site water activities. Water activities will meet state child care licensing regulations.*
HIDE- To Act in an Emergency: I authorize the staff of Little Stars to obtain all or part of the services listed below, for the child referenced below. These services may be used only in the event of a medical emergency, when staff is unable to reach the emergency contact person(s): Act in emergency first aid, obtain outpatient services, necessary lab procedures (blood level Little Stars, x-rays, etc.), emergency surgery, paramedic care, examination.
To Act in an Emergency: I authorize the staff of Little Stars to obtain all or part of the services listed below, for the child referenced below. These services may be used only in the event of a medical emergency, when staff is unable to reach the emergency contact person(s): Act in emergency first aid, obtain outpatient services, necessary lab procedures (blood level Little Stars, x-rays, etc.), emergency surgery, paramedic care, examination.*
HIDE- To Administer Medications: I authorize the staff of Little Stars to administer PRN medications, as approved by a physician, administer medications prescribed by a physician.
To Administer Medications: I authorize the staff of Little Stars to administer PRN medications, as approved by a physician, administer medications prescribed by a physician. *
HIDE- To Photograph: I authorize the staff at Little Stars to photograph my child for purposes of memory albums, photo albums, and marketing (i.e. to show others about our program).
To Photograph: I authorize the staff at Little Stars to photograph my child for purposes of memory albums, photo albums, and marketing (i.e. to show others about our program). *
HIDE- Photographs/Videotape: I give permission for my child to be photographed and videotaped in the center and during program functions and field trips. I understand that photographs/videos may be taken by center staff or by other parents/guardians. I will be asked to sign a separate permission form before any photos/videos are used for Little Stars. public relations purposes and understand I have the right to refuse permission for such use.
Photographs/Videotape: I give permission for my child to be photographed and videotaped in the center and during program functions and field trips. I understand that photographs/videos may be taken by center staff or by other parents/guardians. I will be asked to sign a separate permission form before any photos/videos are used for Little Stars. public relations purposes and understand I have the right to refuse permission for such use.*
HIDE- I have read and understand the Little Stars Grievance Procedure
I have read and understand the Little Stars Grievance Procedure*
HIDE- I have read and understand the Little Stars Handbook Acknowledgement
I have read and understand the Little Stars Handbook Acknowledgement*
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/
Signing Parent/Guardian Name*

First NameLast Name
Signing Parent/Guardian Email*
example@example.com
Parent/Guardian Signature*

Clear
Date of Signature

MonthDayYear
Date
I have reviewed the authorizations for accuracy*

YesNo

Little Stars Grievance Form
Child Name

First NameLast Name
Child's Date of Birth

MonthDayYear
Date
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/
Signing Parent/Guardian Name

First NameLast Name
Signing Parent/Guardian Email
example@example.com
Parent/Guardian Signature

Clear
Date of Signature

MonthDayYear
Date
I have reviewed the grievance form for accuracy*

YesNo

Little Stars Handbook Review Acknowledgement
Child Name*

First NameLast Name
Child Date of Birth*

MonthDayYear
Date
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*

YesNo
HIDE- I have read and understand this agreement

YesNo
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/
Signing Parent/Guardian Name*

First NameLast Name
Signing Parent/Guardian Email*
example@example.com
Parent/Guardian Signature*

Clear
Date of Signature

MonthDayYear
Date
I have reviewed the handbook acknowledgement form for accuracy*

YesNo

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.
Printable Form
Parent and Child Information
#Parent Name

First NameLast Name
#Parent Email
example@example.com
#Parent Phone Number
Please enter a valid phone number.
#Select the number of children enrolled at Little Stars

1 child2 children3 children4 children5 children
#Child 1 Name

First NameLast Name
#Child 2 Name

First NameLast Name
#Child 3 Name

First NameLast Name
#Child 4 Name

First NameLast Name
#Child 5 Name

First NameLast Name
Payment Information
#Initial Deposit Amount
#Card Number
#Expiration Date
#CVV Code
#Billing Zip Code
Authorizations
#I authorize Little Stars Kids Club/Orion Associates to process and charge the credit or debit card account provided in this form for the initial deposit amount due

Clear
#Date of Signature

MonthDayYear
Date
#I authorize Little Stars Kids Club/Orion Associates to process and charge the credit or debit card account provided in this form for the recurring monthly payments

Clear
#Date of Signature

MonthDayYear
Date

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*

YesNo
Please verify that you are human
Should be Empty:

	Relationship to Child	Date of Birth
Family Member 1
Family Member 2
Family Member 3
Family Member 4
Family Member 5
Family Member 6
Family Member 7
Family Member 8

	Type	Amount	Times
Formula
Breastmilk
Milk
Water

Little Stars Forms Library

Little Stars Initial Application

Little Stars Parent/Guardian 1 Information

Parent/Guardian 2 Information

Signatures

Little Stars Authorized Individuals

Authorized Individual 1

Authorized Individual 2

Authorized Individual 3

Unauthorized Individuals

Signatures

Little Stars Emergency Contacts

Emergency Contact 1

Emergency Contact 2

Emergency Contact 3

Signatures

Little Stars Health Care Information

Medical

Dental

Hospital

Insurance Information

Signatures

Little Stars Medical Records Acknowledgement

Signatures

Little Stars Secure Upload

Little Stars Medical Policies Acknowledgement

Signatures

Financial Information and Little Stars Hours of Operation

Signatures

Little Stars Parent/Guardian Authorizations

Signatures

Little Stars Grievance Form

Signatures

Little Stars External Preparations Form

Signatures

Little Stars Handbook Review Acknowledgement

Signatures

Little Stars Personal Resume

Demographic Information

Social Development

Emotional Development

Nutrition Information

Self-Care Information

Medical History

Signatures

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

Parent/Guardian Information

Health Care Provider Information

Specific Allergy Action Plan

Signatures

Little Stars Initial Deposit and Credit Card Authorization Form

Parent and Child Information

Payment Information

Authorizations

Next Steps