YC_AppInitRenew_6_of_6

							Page 6 of 6      YOUTH CAMP APPLICATION - DIRECTOR OR ALTERNATE DIRECTOR WITHOUT PRIOR APPROVAL
LICENSE # ______ CAMP NAME ______________________________________________________________________________CITY/TOWN ________________________

Note: If page 6 is submitted after the camp is licensed, a General Report of Change form must be mailed with this form. Original signatures are required.
SELECT ONE ONLY                Camp Director           Alternate Director Page 6 to be completed by staff that has not had DPH approval within the last seven years.
If multiple site or program camp, which site or program will the alternate be supervising? (Ex: Coed Soccer) ___________________________ & Dates _________________________

INSTRUCTIONS: This form may be duplicated as needed. Each camp license # may request approval for only one Director. The alternate camp director(s) is required to have the
SAME minimum qualifications as the designated camp director. The alternate camp director will be acting camp director whenever the designated camp director is absent from the camp.
The camp director, or an alternate director who is acting as the camp director, cannot act as any of the following: Director of First Aid or Nurse or as any of the following program directors:
Waterfront/Aquatics, Small Craft Waterfront, Riflery or Challenge Courses.

If multiple site or program camp, the camp director is required to be responsible for all programs and/or sites operating under the license and should be thoroughly familiar with
all programs and/or sites. The camp director is responsible for having all information available pertaining to all of the camp’s programs and/or sites.

Section 19-13-B27a(n)(2) of the Public Health Code requires that a camp director have the experience of serving at least one summer as camp director or of serving at least sixteen weeks in
an administrative or supervisory camping capacity satisfactory to the Commissioner.

PLEASE PRINT CLEARLY AND COMPLETE ALL INFORMATION REQUESTED. USE LEGAL FIRST NAME & NOT NICKNAME MUST BE 21 YEARS OF AGE

  Mr. or      Ms. First Name (Legal) __________________ M.I._____ Last Name ___________________ Former/Maiden Name ______________Date of Birth _____/_____/_____
Permanent Address: Street _____________________________ Town_______________ State___________ Zip Code ____________ Permanent Phone # (_____)________________
EXPERIENCE OF DIRECTOR/ALTERNATE DIRECTOR IN AN ADMINISTRATIVE/SUPERVISORY CAPACITY AT AN ORGANIZED CAMP:

             Camp Name                        Camp Street Address               Camp City/Town,          Actual # of Years          # of Weeks of            In What Capacity Did You
                                                                               State and Zip Code        Worked at camp           Experience for each         Work? (Position or Title)
                                                                                                         (Ex.: 2006-2011)        year worked at camp       (Ex: Waterfront, Archery, etc.)




Alternate training or experience, with details (where, when, etc.)________________________________________________________________________________________________

___________________________________________________________________________________________________________________________________________________

Pertinent educational preparation of camp director, (name of college, degree, major and minor, year of graduation) ________________________________________________________

___________________________________________________________________________________________________________________________________________________
I hereby certify that I have not been convicted of any offense involving moral turpitude, have not been declared legally insane or mentally incompetent, and do not illegally use any narcotic
or controlled drug. I promise to uphold and maintain all standards of youth camps required in the Connecticut General Statutes and in the Public Health Code of the State of CT.

Original Signature of Individual Seeking Approval ________________________________________________________________ Date Signed _______/_______/______
As Camp Director or Camp Alternate Director – Note: This page must be mailed - faxed copies of signatures are not acceptable.            Last Revised Jan 2012