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3/2018 Activity-Specific Plan for Sports Page 1 of 7 Sports Activity-Specific 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: 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 this plan for each sport 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). 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 Activity-Specific Plan for Sports Page 2 of 7 Check the box for the sport(s) being conducted at the camp (check all that apply): ☐ Baseball ☐ Basketball ☐ Bowling ☐ Cheerleading ☐ Football ☐ Golf ☐ Handball ☐ Ice Hockey ☐ Field Hockey ☐ Lacrosse ☐ Roller Hockey ☐ Soccer ☐ Softball ☐ Tennis ☐ Volleyball ☐ Wrestling ☐ Other (specify): Enter text here. The activity leader for on-site sporting activities must be competent in the sport they are overseeing. A minimum of the 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 sport 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 Fact Sheets listing approved CPR and First aid certifications are available at www.health.ny.gov/environmental/outdoors/camps or by contacting your local health department. Complete the following sections for each sport conducted at the camp. Sports with the same supervision and safety procedures may be listed together. Use additional sheets if necessary. a) Name of sport(s) Enter text here.: List the required prerequisites for the activity leader (e.g. training, skills, experience, certification): ☐ No specialized prerequisites required ☐ Minimum age: ☐ 16 years-old (day camps only) ☐ 18 years-old ☐ 21 years-old ☐ 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. Does the activity leader need to possess or be accompanied by staff who possesses current first aid and CPR certifications for this activity? ---PAGE BREAK--- 3/2018 Activity-Specific Plan for Sports Page 3 of 7 ☐ Yes ☐ No Camper to Counselor Ratio ☐ 1:8 for campers under 8- years-old ☐ 1:10 for campers 8- years and older ☐ 1:12 (day camps) ☐ Other (specify) Enter text here. Participant prerequisites (training, age, height, weight, skills, etc.): ☐ Minimum age Enter text here. ☐ Sport safety orientation ☐ Other (specify): Enter text here. Required safety equipment ☐ None ☐ Helmet ☐ Elbow/knee pads ☐ Mouth guard ☐ Other (specify): Enter text here. Describe the inspection/maintenance requirements for the safety equipment. Enter text here. ☐ No safety equipment needed Safety rules or precautions taken during the activity Enter text here. 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. ☐ None b) Name of sport(s) Enter text here.: List the required prerequisites for the activity leader (e.g. training, skills, experience, certification): ☐ No specialized prerequisites required ☐ Minimum age: ☐ 16 years-old (day camps only) ☐ 18 years-old ☐ 21 years-old ☐ 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. ---PAGE BREAK--- 3/2018 Activity-Specific Plan for Sports Page 4 of 7 ☐ Training (specify): Enter text here. ☐ Other Skill or knowledge required (specify): Enter text here. 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 Camper to Counselor Ratio ☐ 1:8 for campers under 8- years-old ☐ 1:10 for campers 8- years and older ☐ 1:12 (day camps) ☐ Other (specify) Enter text here. Participant prerequisites (training, age, height, weight, skills, etc.): ☐ Minimum age Enter text here. ☐ Sport safety orientation ☐ Other (specify): Enter text here. Required safety equipment ☐ None ☐ Helmet ☐ Elbow/knee pads ☐ Mouth guard ☐ Other (specify): Enter text here. Describe the inspection/maintenance requirements for the safety equipment. Enter text here. ☐ No safety equipment needed Safety rules or precautions taken during the activity Enter text here. 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. ☐ None c) Name of sport(s) Enter text here.: List the required prerequisites for the activity leader (e.g. training, skills, experience, certification): ☐ No specialized prerequisites required ---PAGE BREAK--- 3/2018 Activity-Specific Plan for Sports Page 5 of 7 ☐ Minimum age: ☐ 16 years-old (day camps only) ☐ 18 years-old ☐ 21 years-old ☐ 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. 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 Camper to Counselor Ratio ☐ 1:8 for campers under 8- years-old ☐ 1:10 for campers 8- years and older ☐ 1:12 (day camps) ☐ Other (specify) Enter text here. Participant prerequisites (training, age, height, weight, skills, etc.): ☐ Minimum age Enter text here. ☐ Sport safety orientation ☐ Other (specify): Enter text here. Required safety equipment ☐ None ☐ Helmet ☐ Elbow/knee pads ☐ Mouth guard ☐ Other (specify): Enter text here. Describe the inspection/maintenance requirements for the safety equipment. Enter text here. ☐ No safety equipment needed Safety rules or precautions taken during the activity Enter text here. 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. ☐ None ---PAGE BREAK--- 3/2018 Activity-Specific Plan for Sports Page 6 of 7 d) Name of sport(s) Enter text here.: List the required prerequisites for the activity leader (e.g. training, skills, experience, certification): ☐ No specialized prerequisites required ☐ Minimum age: ☐ 16 years-old (day camps only) ☐ 18 years-old ☐ 21 years-old ☐ 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. 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 Camper to Counselor Ratio ☐ 1:8 for campers under 8- years-old ☐ 1:10 for campers 8- years and older ☐ 1:12 (day camps) ☐ Other (specify) Enter text here. Participant prerequisites (training, age, height, weight, skills, etc.): ☐ Minimum age Enter text here. ☐ Sport safety orientation ☐ Other (specify): Enter text here. Required safety equipment ☐ None ☐ Helmet ☐ Elbow/knee pads ☐ Mouth guard ☐ Other (specify): Enter text here. Describe the inspection/maintenance requirements for the safety equipment. Enter text here. ☐ No safety equipment needed Safety rules or precautions taken during the activity Enter text here. ---PAGE BREAK--- 3/2018 Activity-Specific Plan for Sports Page 7 of 7 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. ☐ None