FROM:FS8 EKKP €625€39337 { Mississiept State DEPARTMENT OF HEALTH Program Manager Permit Application ‘Camp Name, County (Camp Location Address Phone - Camp Mailing Address Camp Director (i diferent from manager) Address Phone = *Peogram Manager (Applicant) Phone, _. Address Program Manager Permit “is the permit to operate a camping facility. This individual is responsible for the staff supervision and program administration. The above may or may not be the Camp Director." The Program Manager ‘and Camp Director may be interchangeable and in those instances (group rental, ete) the Program Manager nmist docurnent the same qualifications as the Camp Director. ach residential catup shall have a Camp Director on premises who shall meet at least two As per the regulations." of the following criteria" ‘A. Beat least 25 years of age: 25 or over__Yes__No B. Have successfully completed a course in camping administration such as those offered by national professional ‘camping associstionnational agencies or their equivalent Course. ‘Agency. Date. (C. Have had at least rwo years previous experience as part ofthe administrative staff of a youth eamp, Camps, _ Date, Aquatics Director —— Ace. (Centfication Agency/Level__ Expiration Date ‘The camp session wil begin, andend, Will aquatics activities be offered? _yes_no Will watercraft activities be offered?__ yes _n0 Estimated number of campers per session Estimated number of staff per session Thave been issued copies of Rules and Regulations Governing Licensure of Youth Camps, [have read the segulations and hereby certify the camping program is in compliance with the said regulations. I understand the permit issued on the basis of this statement is subject to revocation if itis established that any of the rules and regulations have not been met. Date. Signature of applicent 570 East Woodrow Wilson * Post Office Box 1700 Jackson, Mississippi 39215-1700 (GO1S76-7634 © Fax 60157647931 » www HealthyMS.com Equal Oppomaniy In Employmene/ervice