APPLICATION FOR / RENEWAL OF A PERMIT TO OPERATE RECREATIONAL CAMPS This application must be completed for each new recreational camp or an existing recreational camp. Return this application to the Environmental Health Field Service in the county in which the camp is located, and please make a photocopy for your records. AN APPLICATION MUST BE SUBMITTED FOR EACH CAMP AT LEAST 30 DAYS PRIOR TO OPERATING CAMP. INCOMPLETE APPLICATIONS MAY BE RETURNED. PLEASE PRINT OR TYPE. Environmental Health Field Services Environmental Health Field Services Environmental Health Filed Services 2055 Limestone Rd Suite 100 Thomas Collins Building Suite 5 Georgetown Service Center Wilmington DE 19808 540 S DuPont Highway 544 Bedford St. Phone: 302-995-8650 Dover DE 19901 Georgetown DE 19947 Fax: 302-995-8323 Phone: 302-744-1220 Phone: 302-856-5496 Fax: 302-739-1957 FAX: 302-856-5065 NAME OF CAMP: ___________________________________________________________________________________________________ LOCATION:_________________________________________________________________________________________________________ ADDRESS:__________________________________________________________________________________________________________ PHONE:____________________________________________________________________________________ OPERATED BY:___________________________________________________________________________________ (List name of individual, club, corporation, etc.) OPENING DATE:__________________________________ CLOSING DATE:__________________________________ DIRECTOR: (Full name):________________________________ EMERGENCY PHONE #: _________________ TYPE OF CAMP PERMIT REQUESTED: __________ DAY __________ PRIMITIVE __________ HOSTEL__________ RESIDENTIAL__________ TRAVEL __________ TROOP REQUESTED CAPACITY:________________ PERSONS AND / OR CAMPSITES: ________________ DO YOU PLAN TO OPERATE IN SESSIONS: YES__________ NO__________ IF YES, NUMBER:__________ AND LENGTH OF SESSIONS:___________ NUMBER OF STAFF:__________ # OVER 18: MALE____________ FEMALE_____________ # UNDER 18: MALE__________ FEMALE__________ Has any member of the Staff or operation ever been convicted of a Felony or Class “A” Misdemeanor? YES___ NO ___ If YES, identify Type of Offense, Date, Location and name of Person Convicted. TYPE OF FACILITIES: PERMANENT BLDGS__________ TENTS__________ OTHER__________ NUMBER OF TOILET FACILITIES: MALE__________ FEMALE__________ NUMBER OF SHOWER FACILITIES: MALE__________ FEMALE__________ In accordance with State of Delaware Regulations Governing the Sanitation of Recreational Camps adopted under Title 16 Del. C. Section 122, I, the undersigned, hereby make application for permit to operate a recreational camp. SIGNATURE_______________________________________________________ DATE________________________ PRINTED NAME____________________________________________________ OFFICIAL USE ONLY PERMIT RECOMMENDED: ANNUAL__________ PROVISIONAL__________ CAPACITY__________ EHFS SUPERVISOR: ______________________________________________ DATE: _____________ HSP PLAN REVIEW ACTION: APPROVED_______ DISAPPROVED_______ DATE: _____________ ADMINISTRATOR: _ DATE: _____________ PERMIT NUMBER: _______________ DATE ISSUED: _________________ TYPE: _____ ANNUAL _____PROVISIONAL 02/07 Doc. No. 35-05-20/08/06/13