USVI Public Records

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GOVERNMENT OF THE VIRGIN ISLANDS OF THE UNITED STATES Department of Human Services Office of Child Care & Regulatory Services Children’s Camp Registration □ 3011 Golden Rock Christiansted St. Croix, VI 00820-4355 Phone: (340)773-2323 Fax: (340)773-6121 □ Knud Hansen Complex Bldg. A 1303 Hospital Ground St. Thomas, VI 00802 Phone: (340)774-0930 Fax: (340)774-9702 I. Name of Camp: Telephone: Physical Address of Camp: Mailing Address of Camp: Email address: Directions to Facility: Check Type of Facility: Church Commercial Corporation Partnership Proprietorship Public Agency II. Name of Operator/Director: Last First Middle Home/Cell Phone Home & Mailing Address: III. Check Type of Operation: Full Day Half Day Overnight Other (Specify) Hours of Operation: From: To: Days Per Week: Sunday Monday Tuesday Wednesday Thursday Friday Sat Duration of Camp, (Month/Date): From: To: Please indicate any variations in established fee, for example, more than one child in the same family. Camp Monthly Fee Registration Fee Insurance Description of Services/Program: Cultural Sport Recreational Partnership Other Proposed Maximum Capacity: Total number of children (include children of operator & staff) Minimum Age Maximum Age Full-time Staff Part-time Staff IV. 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 regulations for children’s camp and agree to operate my camp in accordance with these regulations. Signature Date Note: Please attach the flyer and schedule of activities for your camp. (Children’s Camp Registration Forms should be completed by an operator or director who have a current license or certificate.) Revised 6/29/20