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Vill. PROGRAM ADMINISTRATION
<br />Have you developed, or revised since last licensure, the following:
<br />How do you insure
<br />Oulet
<br />that naps or rest meet the needs of children and the wishes of parents
<br />aeti v ties are provided Such as puzzles
<br />Policies for Parents? ❑Yes ❑No Personnel Policies? ❑Yes ❑Nn
<br />Explain:
<br />Crayons,
<br />Paper Book,;.
<br />Health Policies? nYes,QNo Job Description? ❑Yes []No
<br />_
<br />Do you administer, or plan to administer medications? lAYes ❑No Only Medication prescribed
<br />by the Docte,r
<br />in oroginal
<br />bottle with prescription
<br />label.Medi
<br />0o you enroll, or plan to enroll children with handicaps? ❑Yes ❑No
<br />cal permission form has
<br />to be filled out by Parents. Pilo other med. i
<br />IX. ATTACHMENTS This application is not complete until all attachments are submitted and the applicable licensing i-; paid.
<br />DIAS THESE FORMS MUST BE SUBMITTED BY ALL PROGRAMS
<br />REQUIRED ONLY FOR NEW PROGRAMS (PROVISIONAL LICENSE)
<br />USE
<br />❑ ❑Ecit pment & Supplies Form(s) (Provisional and first renewal application
<br />❑
<br />❑ Admission (enrollment) Forms
<br />only]
<br />❑
<br />❑ Articles of Incorporation, U incorporated
<br />❑ ❑ Personnel information for new staff and staff who change positions
<br />❑
<br />❑ Floor Plan/Outdoor Play Space Plan
<br />❑ ❑ Staffing Information
<br />❑
<br />❑ Health Policies for Center
<br />❑ ❑ Staffing Pattern
<br />❑
<br />❑ Job Desc,;�,�,ns
<br />❑
<br />❑ Personnel Policies
<br />❑
<br />❑ Policies for Parents
<br />❑
<br />❑ Program Plan
<br />❑
<br />❑ Sample Menu(s)
<br />n
<br />1 Statement of Goals amj Philosopf, • of Program
<br />X. AGREEMENT
<br />I will comply with the provisions of the Department of Human Services Ruie 3. 1 understand that a representative of the Commissioner has the right to visit
<br />the facility during operating hours. I understand that DHS has the right to request documentation of compliance with licensing standards. I agree to make
<br />available information necessary to determine if standards are being met. I will maintain sufficient financing to meet licensing standards and will operate In
<br />accordance with fair employment laws.
<br />agree not to discriminate against any person because of race, color, race, or national origin.
<br />I will notify the Licensing Consultant, in advance, of changes in the terms of the license i.e. auspicies, facility, hours or operation, number and ages of children.
<br />Notice: You are advised that a check will be made by this agency regarding all criminal conviction data, arrest information, reports regarding abuse
<br />or neglect of children, and investigation results available from local, state and national criminal history record repositories, Including the
<br />criminal justice data communications network, about persons connected with the facility or agency for which a license application Is made.
<br />The information on this application and supporting documents is true and complete to the st of my knowledge.
<br />Signature Of board chairman
<br />�o
<br />Signature of director
<br />Sponsor, if any
<br />Date
<br />q/_5LS-6
<br />► Date
<br />Please Return Completed Form
<br />Department of Human Services
<br />Licensing Ulvislon
<br />Centennial Office Building
<br />St. Paul, MN 55155
<br />Phone No.:296 3971
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