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Children’s Camp Forms


Download forms necessary for lawful operation of children’s camps through the following links:

Application for a Permit to Operate (DOH-3915, PDF, 147K)

Instructions: Complete, sign and return at least 60 days prior to expected opening date.

Children’s Camp Written Plan Checklist (DOH-2040, PDF, 26K)

Instructions: Use the following checklist to determine if your written plan addresses the requirenemts of Subpart 7-2 of the New York State Sanitary Code. Please submit the completed checklist with your written plan or revision.

Prospective Children’s Camp Director Certified Statement (DOH-2271, PDF, 172K)

This statement is relative to conviction of a crime or the existance of a pending criminal action. Complete, sign and return at least 60 days prior to expected opening date.

Statewide Central Register Database Check Form
(LDSS-3370, Rev 4/2009. MS Word doc, 355KB)

Complete the form for yourself, your spouse, your children and any other person(s) in your home at the present time. Make sure you complete all maiden name/alias sections that apply. If none, state “none”. The form must be signed and returned to the Health Department at least 60 days prior to the expected opening of camp.

The purpose of collecting the demographic data on other persons in your household who are not screened pursuant to Section 424-a of the Social Services Law is to enable the N.Y.S. Office of Children and Family Services to identify with the greatest degree of certainty, whether the person(s) being screened is the subject of an indicated child abuse or maltreatment report. The utilization of this information in a discriminatory manner is contrary to the Human Rights Law.

Children’s Camp Facility and Staff Description (DOH-367, PDF, 100K)

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. Questions should be directed to the LHD that has jurisdiction in the county that the camp is located.

Children’s Camp Additional Staff Qualifications (DOH-367a, PDF, 23K)

Instructions: Local health departments may require children’s camp operators to document staff ratios and qualifications by submitting this form and /or copies of certification cards. Complete the applicable items and submit this form for review as directed by the local health department (LHD) that has jurisdiction in the county where the camp is located. Use additional sheets if necessary. 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. Copies of all required certifications must be maintained on file at the camp. All code citations refer to Subpart 7-2 of the New York State Sanitary Code.

Poster heading
Poster: Required Reporting for Injury and Illness (DOH Form 3602.) Download PDF for printing (Legal size 8-1/2 x 14, 199K)

Illness and Outbreak Report (DOH-61b, PDF, 21K)

Instructions: Local health department staff are responsible for completion of the form and submittal to the Bureau of Community Sanitation and Food Protection. Victim information is confidential and must be protected from unauthorized disclosure.

Injury Report (DOH-61a, PDF, 25K)

Instructions: Local health department staff are responsible for completion of the form and submittal to the Bureau of Community Sanitation and Food Protection. Victim information is confidential and must be protected from unauthorized disclosure.

Multiple Victim Injury Report Form (DOH-61h, PDF, 23K)

Instruction: Local health department staff are responsible for completion of the form and submittal to the Bureau of Community Sanitation and Food Protection. Victim information is confidential and must be protected from unauthorized disclosure.

Potential Rabies Exposure Report (DOH-61-rabies, PDF, 25K)

Instructions for Completing the Children’s Camp Rabies Exposure Report Form: For each exposure incident, complete the requested information for all persons exposed. A separate form must be utilized for each incident. An incident can be exposures of one or more people to one or more animals over the course of a period of time (onsite petting zoo) or to a single animal one time. The local health department Rabies Coordinator must be consulted to arrange for and determine the appropriateness of postexposure prophylaxis (PEP). A copy of the Children’s Camp Potential Rabies Exposure Incident Report should be sent to the Rabies Coordinator for their records. When an exposure occurred over a period of time, indicated the first exposure date and time as that for the incident and specify each victims exposure date and time in the victim information section.

Fire Report Form (DOH-61-fire, PDF, 16K)

Instructions: Local health department staff are responsible for completion of the form and submittal to the Bureau of Community Sanitation and Food Protection. Victim information is confidential and must be protected from unauthorized disclosure.

Allegation of Abuse Report Form (DOH-61-abuse, PDF, 22K)

Instructions: Local health department staff are responsible for completion of the form and submittal to the Bureau of Community Sanitation and Food Protection. Victim information is confidential and must be protected from unauthorized disclosure.

Epinephrine Administration (DOH-61e, PDF, 19K)

Instructions for completing the Children’s Camp Epinephrine Administration Report: Local health department staff are responsible for completion of the form and submittal to the Bureau of Community Sanitation and Food Protection. Victim information is confidential and must be protected from unauthorized disclosure.

Children’s camps must report epinephrine administration to the local health department whether or not they are participating in the auto injector program and regardless if medication was from the camp’s stocked supply or brought to camp by a camper or staff.

Sample Meningococcal Meningitis Vaccination Response Form (MS Word Document, 25K)
Sample overnight children’s camp parent letter (MS Word document, 34K)

New York State Public Health Law requires that a parent or guardian of campers who attend an overnight children’s camp for seven (7) or more consecutive nights, complete and return the Vaccination Response Form to the camp. You may copy form and letter onto your children’s camp letterhead. For a fact sheet about Meningococcal disease, click here.

Sex Offender Registry Fact Sheet (pdf)

 

See also: New York State Department of Health, Children's Camps