{ Mississieet STATE DEPARTMENT OF HEALTH Program Manager Permit Application County Phone Camp Director (if different from manager) Addr: hon: Phone. “Program Manager (Applicant) Address Program Manager Permit "is the permit to operate a camp superveion and program administration. The abov® ray or may ‘ind Camp Director may be interchangeable and in those instances ( document the 5 Carp Director. Tavility. This individual is responsible for the staff not be the Camp Director.” The Program Manager coup rental, ete.) the Program Manager must at least two [As per the regulations." Each of the following criteria! Have had at east two yours previous experience as part ofthe administarive staff of « youth emp Camps. - _ Date, Aquatics Director Age. cpiration Date Certification Ageney/Level__—_—_—__————— ‘The camp session vill begin____ and end “Will aquatics activities be offered? _yes __n0 ities be offered? ___yes__n0 ‘Will watercraft Estimated number of campers per session Estimated number of staff per session FERCL SEE NST pI OF Rules tnd Regulations Governing Licensure of Youth Camps. Us rat the rane onan sna hereby cemtify the camping program sin compliance wit the said regulations f ‘understand the ‘rc psd onthe bess of this Statement i subject to revocation itis established Wat any of the rules and regulations have not been met. Date ature of applicant 0x 1700 * Jackson, Mississippi 39215-1700 570 East Woodrow Wilson * Post Office 981» ww HealthyM5.com 01576-7634 «Fax 6015 qual Oppattunity In SmpoymentiServi