Full Text
NEW YORK STATE DEPARTMENT OF HEALTH Bureau of Community Environmental Health and Food Protection Instructions Complete the items that are applicable to the camp’s operation; use additional sheets if necessary. Submit the completed form and other required application materials to the local health department (LHD) at least 60 days prior to camp operation. Information that is not available should be identified as “Pending.” For expired certifications, the date of scheduled re-certification courses may be listed when staff are registered to attend. Pending information and confirmation of staff re-certification must be sent to the LHD when available. Facility Facility Name: Facility Code: Date Date Close: Are 20% or more of the campers developmentally disabled? Yes No Activities available to campers For activities identified with a please further specify the activity in the space provided. Children’s Camp Facility and Staff Description Amusement Parks Aquatic Theme Parks Archery Arts and Crafts Bicycling Boating/Canoeing/Rafting Camp Trips Classroom Instruction Cooking Dancing/Acting Gymnastics High Adventure* Hiking Horseback Riding Ice Skating Martial Arts Mountain Boarding Nature Study Organized Games (Play) Petting Zoo Riflery Roller Skating/Blading Ropes/Challenge Course Skate Boarding Sports Swimming – On-Site Swimming – Off-Site Swimming – Wilderness Other Water Activities* Other* * Camper Capacity For each session, select the camp type, specify the number of days in the session and provide camper capacity information. Use separate session rows if both a day camp and overnight camp operate at the same time. Use actual attendance data from last season. If the camp did not operate last season, use estimates and check this box . Attach additional sheets if needed. Camp Type Age Group Day Overnight Number of Days 1 to 5 6 & 7 8 to 12 13 to 15 16 & 17 CITs male female male female male female male female male female male female Session 1 Session 2 Session 3 Session 4 Session 5 Session 6 Session 7 Session 8 Session 9 Session 10 A counselor-in-training (CIT) must be 15 years old at a day camp and 16 or 17 years old at an overnight camp. CITs that do not meet the minimum age requirements must be accounted for as a camper. Camp Director Name of Camp Director: Date of Birth: Education: Qualifying Experience: A “State Central Register Database Check” form (LDSS-3370) and a “Prospective Children’s Camp Director Certified Statement” form (DOH-2271) must be completed by the Camp Director and submitted to the LHD with this form. Camp Health Director Name of Camp Health Director(s): Attach additional sheets if more than one Health Director is used. Qualifications (certification, licenses, etc.) Doctor Nurse Practitioner Physician Assistant RN LPN EMT Other NYS License Number: For day camps only: Will the Health Director be located on-site or off-site? On-site Off-site Certifications List the Course Provider, Course Title and certification issuance date for each certification held by the Camp Health Director or Designated Assistant. (See Section 7-2.8 for requirements) Certifications Staff Possessing Certification Course Provider Course Title Issue Date CPR Health Director Assistant / / First Aid Health Director Assistant / / DOH-367 (1/12) pg. 1 of 2 ---PAGE BREAK--- Aquatics Director Name of Camp Aquatics Director: Date of Birth: Certifications List the Course Provider, Course Title and certification issuance date for each certification held by the Camp Aquatics Director. (See Section 7-2.5(e) for minimum qualifications) Certifications Course Provider Course Title Issue Date Lifeguard Supervision and Management* / / Lifeguarding / / Progressive Swimming Instructor / / CPR* / / First Aid / / * The Camp Aquatics Director must possess these certifications to qualify. Aquatic Experience (check qualifying experience below) One season of previous experience as a camp aquatics director at a New York State children’s camp. Two seasons of previous experience consisting cumulatively of at least 12 weeks as a children’s camp lifeguard, as specified in Section 7-2.5(g), at a swimming pool or bathing beach which had more than one lifeguard supervising it at a time. At least 18 weeks of previous experience as a lifeguard, as specified in Section 7-2.5(g)(2), at a swimming pool or bathing beach which had more than one lifeguard supervising it at a time. Other Staff Requirements Subpart 7-2 of the New York State Sanitary Code (Children’s Camps) specifies minimum staff ratios and qualifications for counselors, lifeguards, progressive swimming instructors, riflery instructors, and additional first aid and CPR certified staff. When staff are required to possess special certification, a course standard or criteria is specified in the regulation. Certification courses which have been reviewed and meet or exceed the Children’s Camp Code standard/criteria, are listed on New York State Department of Health (NYSDOH) “fact sheets.” The fact sheets are available from the LHD and at the NYSDOH’s website at www.health.ny.gov. Camp operators are responsible for ensuring that required staff are present and possess acceptable certification. A LHD may require a children’s camp operator to document staff ratios and qualifications by submitting a Children’s Camp Additional Staff Qualifications form (DOH-367a) and/or copies of certification cards. Copies of all required certifications must be maintained on file at the camp. Written Safety Plan, Facility Additions/Modifications, and Itinerary of Camp Trips 1. Written Safety Plan as required by Section 7-2.5(n) Plan attached Previously submitted on This plan remains up to date and complete. Update to plan attached 2. Facility Addition/Modifications Provide a list of additions or modification to the camp that have been made since last season or that are planned prior to this season. Include additions or modifications to buildings (cabins, kitchens, dining halls, infirmary, assembly areas, privies and toilets, etc.), potable water and sewage disposal systems, swimming pools, bathing beaches, activity areas (challenge course, archery and rifle ranges, etc.), emergency access and egress roads and any other camp facilities. List attached No Addition/Modifications Not Applicable. Camp did not operate last season. 3. Itinerary of Camp Trips Attach a list of camp trips. Describe the activities that will take place (swimming, canoeing, hiking, etc.) and include the trip date(s) when known. List attached No trips Section 7-2.5(p) requires a written statement or brochure outlining the rights and responsibilities of campers and camp operators to be provided to parents or guardians of campers by the camp operator with any enrollment application forms and/or enrollment contract forms. Either a statement or brochure prepared by the camp and approved by the permit-issuing official or the Department of Health brochure “Children’s Camps in New York State” may be used. Please check the appropriate box below for the brochure sent with your application materials. A statement (brochure) which has been submitted to the DOH and approved “Children’s Camps in New York State” Brochure (#3601) I certify that the information given in this form is true. Signature of Camp Operator: Print Name: Title: Date: DOH-367 (1/12) pg. 2 of 2