USVI Public Records

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DHS-CAMP-R GOVERNMENT OF THE VIRGIN ISLANDS OF THE UNITED STATES Department of Human Services Licensing & Regulatory Services CHILDREN’S CAMP REGISTRATION I. Name of Facility: _______________________________________________ 1 Street Address: _______________________________________________ Mailing Address: _______________________________________________ Telephone: ____________________________ Direction to Facility:_____________________________________________________________ FOR USE BY DHS ONLY Registration Date____________ Date Approved_____________ Date Denied _______________ Check Type of Facility: Church Proprietorship Public Agency Commercial Partnership Corporation II. Operator/Director: Person Responsible: SS#: _________________ 1. Name: ____________________________________________ ____________ Last First M.I. Res. Phone Mailing Address: ____________________________________ ____________ Bus. Phone Residence: _________________________________________ III. Type of Operation 1. Full Day Half Day Over Night Other (Specify) ______________ 2. Hours of Operation: From______ to _______ Days per Week: M T W T F S S (Circle each day open) 2 3. Description of Services/Program: Recreational Cultural Sports Other (Specify) __________________________ 4. Proposed Capacity: Total Number of Children (Include children of operation and staff) _______________ Minimum Age_________________ Maximum Age_________________ Number of staff (Full-time)_______________ Part Time________________ 5. Camp Fees – Monthly Fee (Indicate any variations in established fee, for example, for more than one (1) child in same family) ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Registration Fee (if any) $____________ Insurance Fee (if any) $______________ 6. Camp Dates: Starting: ______________ Ending: ______________ IV. 1. Attachments – Attach a Copy Of All forms, brochures, etc. to be used Schedule of activities V. I certify that I have not been convicted of a crime involving child abuse, child neglect or moral turpitude, and have not hired any person with aforementioned conviction to work at the camp. I have received a copy of the Virgin Islands Rules and Regulations for Children’s Camps and agree to operate my camp in accordance with these regulations. _______________________________________________________________________ _________________________________ ________________ Signature Date __________________________________ _________________ Signature of Licensing Specialist Date