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3/2018 Page 1 of 3 Activity Plan Camp Name: Enter text here. Date: Enter a date. Prepared By: Enter text here. Title: Enter text here. Phone number: Enter text here. Email Address: Enter text here. Signature: For Health Department Use Only Approved: ☐ Yes ☐ No Reviewer: Enter text here. Date: Enter a date. Comments: Enter text here. Complete the following plan for each activity without an Activity-Specific Plan or that requires additional supervision or safety procedures from what has been provided in Section V (Supervision and Activity Safety) of the main document (e.g. requires additional/specialized staff, minimum participant prerequisites, safety equipment). Activities that have similar safety and supervision procedures may be listed on the same worksheet. Submit the completed plan to the local health department or State District Office that has jurisdiction in the county where the camp is located for review. A copy of the approved plan must be maintained at the camp and reviewed by the activity leader prior to overseeing the activity. ---PAGE BREAK--- 3/2018 Page 2 of 3 ACTIVITY: Enter text here. SUPERVISION • Each activity at camp must be supervised by an activity leader that is competent in the activity being conducted. Activity leaders of an activity that includes wilderness hiking, camping, rock climbing, horseback riding, bicycling, swimming and/or boating must be at least 18 years of age. • A minimum of one activity leader and one staff member must supervise activities that occur at locations where additional camp staff assistance is not readily available (within five minutes). • When the activity is conducted at a location where the camp staff certified in first aid and CPR are not readily available, the activity leader must possess or be accompanied by staff who possesses current first aid and CPR certification in an approved course. NYSDOH Factsheets listing approved CPR and First Aid certification are available at www.health.ny.gov/environmental/outdoors/camps or by contacting your local health department. 1. What ratio of counselors to campers will be maintained for this activity? ☐ 1:8 for campers younger than 8-years-old ☐ 1:10 for campers 8-years and older ☐ 1:12 (day camps only) ☐ Other (specify): Enter text here. 2. List the required prerequisites for the activity leader (e.g. training, skills, experience, certification): ☐ No specialized prerequisites required ☐ Minimum age: ☐ 18 years-old ☐ 21 years-old or older ☐ Other (specify): Enter text here. ☐ Experience (specify in number of weeks or other quantifiable time period): Enter text here. ☐ Certification(s) (specify): Enter text here. ☐ Training (specify): Enter text here. ☐ Other Skill or knowledge required (specify): Enter text here. 3. Does the activity leader need to possess or be accompanied by staff who possesses current first aid and CPR certifications for this activity? ☐ Yes ☐ No 4. At a minimum, there must be visual or verbal communications capabilities between campers and counselors at all times during the activity. Describe any specific duties of the activity leader, counselors and other specialty staff (if any) for this activity: Enter text here. ---PAGE BREAK--- 3/2018 Page 3 of 3 PARTICIPANT PREREQUISITES AND SAFETY PROCEDURES 5. List participant prerequisites, if any (e.g. training, skills, experience, age). ☐ No participant prerequisites ☐ Activity safety orientation including, but not limited to, instruction on the following topics: Enter text here. ☐ Other (specify): Enter text here. 6. What safety equipment will be used? ☐ No safety equipment needed ☐ Helmet ☐ Safety goggles ☐ Earplugs ☐ Gloves ☐ Mouth guard ☐ Lifejacket ☐ Shin guards ☐ Long pants ☐ Other (specify): Enter text here. 7. Describe the inspection/maintenance requirements for the required equipment: Enter text here. ☐ No safety equipment/techniques needed 8. What are the rules and/or safety precautions that will be taken during the activity? Enter text here.