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REBEL SHAKESPEARE CAMP 2014 Owe.® UNV-12110 WOEMII81� MEN=s Omr w-a0 �Y u In {' City of Salem, Massachusetts q Board of Health " n 120 Washington Street,4th Floor, Salem, MA 01970 PllblicHealttl Tel. (978) 741-1800 Fax. (978) 745-0343 Prevent. Promote. Protect. Kimberley Driscoll Iramdln@salem.com Larry Ramdin RS/RENS, CHO, CP-FS Mayor Health Agent CAMP PERMIT Permit# License For : Recreational Camp CA-14-30 Date of Print Granted To: Rebel Shakespeare Co. 6/24/2014 Address: Winter Island Park Salem MA 01970 Permit Issued 6/24/2014 Location of Establishment: Permit Expires 8/30/2014 Permit Fee Restrictions: $10.00 Late Fee Notes: Winter Island Park $0.00 This permit or license is granted in conformity with the statues and ordinances relating thereto, and expires on 8/30/2014 unless sooner revoked or suspended. -- CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH n 120 WASHINGTON STREET, 4TH FLOOR SALEM,.MA 01970 TEL. 978-741-1800 FAX 978.745.0343 STANLEY J. USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO MAYOR HEALTH AGENT APPLICATION FOR LICENSE TO CONDUCT A RECREATIONAL CAMP Name of Camp: `��1��G� (f C(]MP�Nu TeI# q7 "2 1 544' Address of Camp: �..14C,2(/RN 'LLI I S. 1, 11 -4 ��0 �� S:I d 1 N�IYu Name of Camp Director: KC,Q( Camp Director mailing address: I 4Coc-a I - M� �tC_/11�� DAOt45 Dates of operation:From: b I Zs I To: 71301 I TypeofCamp: ay: Recreational:_--5ports:=Travel: drip Approximate#of campers:25 Campers Ages r 15#of counselors: Please attach the following information ✓ Medical consultant agreement and camp medical policy. Buildin Check payable to the City of Salem ($10). ' Written copies of your Emerge cy, Special Contingency and StaffOrientation plans. I agree to comply with all mandates of the State Sanitary Code, Chapter IV, 105 CMR 340., "Minimum Standards for Recreational Camps for Children'. I understand that noncompliance may result in suspension of this license. Pursuant to MGL Chapter 63C, Section 49A,1 certify under the penalties of perjury that I,to my best knowledge and belief,have filled all state tax returns and paid all state taxes required under the law. J Signature �"4 Date J SSS#or Federal Identification Number C_1..........................................................................c_ .. ....Ze 5.................Gl ..........(011T.(14............................... Revised 7/11/03 recc.amp app. Check#&Date - HEALTH CARE CONSULTANT AGREEMENT fie ( S'L,a 120. .%x4 crga a Vmj� NAME OF CAMP ADDRESS OF CAMP The Massachusetts Department of Public Health regulations for recreational camps for children, 105 CMR 430.000,require that all recreational camps for children have a health care consultant. The regulation and responsibilities of this person are described below. 430.159(A) Health Care Consultant A designated Massachusetts licensed physician,nurse practitioner or physician assistant with pediatric training as the camp's health care consultant. The consultant shall: 1. Assist in the development of the camp's health care policy as described in 105 CMR 430.159(B); 2. Review and approve the policy initially and at least annually thereafter; 3. Approve any changes in the policy; 4. Review and approve the first aid training of the staff-, 5. Be available for consultation at all times;and 6. Develop and sign written orders to be followed by the on-site health supervisor in the administration of hisfher related duties. If the health supervisor is not a licensed health care professional authorized to administer prescription medications,the administration of medications shall be under the professional oversight of the health care consultant. 105 CMR 430.160(C) 430.159(B) Health Care Policv A written medical policy,approved by the local board of health and by the camp health care consultant. Such policy shall include,but not be limited to,daily health supervision,infection control,handling of health emergencies and accidents,available ambulance services,provision for medi`cal,nursing and first aid services,the name of the designated on-site camp I health supervisor,the name,address and phone number of the camp healthcare consultant required by. 105 CMR 430.159(A)and the name of the health supervisor required by 105 CMR 430.159(E),if applicable. 430.160(C) Administration of Medication The health care consultant shall acknowledge in writing a list of all medications administered at the camp. • I meet the requirements of the Health care consultant as described in 105 CMR 130.159(A). I have reviewed theses referenced regulations and understand the responsibilities of the position and agree to assist this camp regarding the same. nt N Title 'n51 Si tore MA License/Registration Number l Address M L ` ` ` 'Telephone Number Date: a February 24,2000 STA�-F O�.l�t"�'fl DUB All Orientation Points: Summer 2014 Staff: Here is what we will be covering at our orientation on June 20-24th in addition to planning our curriculum and reading the script together. To Review - Review Winter Island map A. Bathrooms: students must be accompanied by staff B. Stage Area C. Pavillion: used as our rain location D. Rain Location: others E. Cottage: no students, staff only F. Routine parent drop-off/pick-up G. Shoes MUST be worn at all times - Check in with Island Manager Dave Gilbert and any new Island Staff - Go over all Health Forms in detail - Discuss pertinent learning disabilities & our course of action. - Divide into Basics Groups : Each staff oversees five students - Go over Department of Health requirements A. .First Aid/CPR: all of you are certified this year! B. Location of First Aid kit: in Cottage, top two drawers C. Protocol for injured child/medical log. D. Protocol for fire/ fire drill first day - Go over Lunch/Snack routines/ check for icepacks on first day. A. Ice packs in all lunchboxes B. No kids eating alone C. Adequate water for the day/frequent water breaks D. Clean up 8s location of trash receptacles - Morning routine A. MAEVE checks off all kids as they enter: hands list to Keri by 9:20am B. MAEVE calls parents if a child does not show up (see procedures book) C. Daily: Make sure kids have sunscreen and a blanket - Afternoon Routine A. General clean up of rehearsal areas B. Two directors lead children to drop-off location REVIEW STAFF HANDBOOK AS A GROUP, then final question and answer session.. Orientation of Program Curriculum: Will be completed June 20th-24th prior to the start of the program. Attendance all 4 days is mandatory. The RebelShakespeare Company SUMMER 2014 Pick-up and Drop-off Policies Students and parents/guardians are instructed to take care when students are entering or exiting vehicles. Students will stay on the sidewalk or shoulder. Parents/guardians should not drop off a child unless a director is present at the drop-off point. Parents/guardians will make every effort not to impede the normal flow of traffic when dropping off or picking up their child/ward. CHILDREN ARE ONLY TO BE RELEASED TO THE DESIGNATED PARENTS/GUARDIANS IDENTIFIED ON THE WAIVER FORM, UNLESS A SIGNED LETTER FROM THE PARENT/GUARDIAN DESIGNATES AN ALTERNATE ADULT WHO IS AUTHORIZED TO PICK-UP THEIR CHILD/WARD. ALTERNATE ADULT MAY BE ASKED FOR IDENTIFICATION IF NOT ALREADY KNOWN TO THE DIRECTOR. Contingency Plans If a student fails to arrive in the morning as scheduled: • Double check attendance. • Call parents/guardians or other contact name provided on the student's application form. If a student is missing from the point of pick-up at the end of the day: • Double check attendance • Check with other directors to see if student was picked up early by parents • Check area in accordance with "Lost Student Plan" For unregistered children arriving with registered student: • Check with student's parent/guardian if still onsite • Find out which student the unregistered child arrived with, and their relation: friend, brother, sister, etc. - obtain contact information from forms • Call the child's parent/guardian if the student's phone number is obtained. Keri Cahill, Artistic Director P.O. Box 847 Salem, MA 01970 978-239-5741 RebelShakespeare@gmail.com The Rebe(Shakespeare Company Lost Student Plan • Report the missing student to the main office, includingthe following g information: o Student's name and age o Last place the student was seen o What the student was wearing • Conduct a search of bathrooms, grounds, and other program areas. • Check whether student was picked up by parent or made other special arrangements. If not, contact parent/guardian to determine if the child was picked up without notifying the directors. • Notify emergency personnel (call 911) if the student is not found immediately or requires emergency medical attention. Disaster Plans General: • If advised by authorities to evacuate an area, do so immediately. • Each director must personally,notify the students assigned to them to evacuate or retreat to shelter as appropriate. • Students and staff should follow emergency personnel directions for evacuation to emergency facilities/shelters. Tornado or High Winds • Go to a basement (if available) or to interior rooms and halls on the lowest floor. Stay away from glass enclosed places or areas with wide-span-roofs. • Crouch down against the floor and cover the back of your head and neck with your hands. • If no suitable structure is nearby, lie flat in the nearest ditch or depression or naturally sheltered area and use your hands to cover your head. Stay away from the trees. Keri Cahill, Artistic Director P.O. Box 847 Salem, MA 01970 978-239-5741 RebelShakespeare@gmail.com The RebelShakespeare Company Lightning • When indoors, avoid using the telephone (except for emergencies) or other electrical appliances. Cellular phones are ok. • When outside, go to safe shelter immediately. Avoid isolated trees or other tall objects, bodies of water, wooden sheds or fences. Brick structures are ok. • If you feel your hair standing on end, squat down with your head between your 'knees. Do not lie flat. Fire Evacuation Policies • A fire drill shall be held during each session on the first day of attendance at each new facility/location at which the program takes place. • In the event of a fire emergency, each director is responsible for their assigned students. Keri Cahill, Artistic Director P.O.' Box 847 Salem, MA 01970 978-239-5741 RebelShakespeare@gmail.com The RebeCShaespeare Company Health Care Consultant: Dr. Jack Weltner Health Care Supervisor: Ryan Buchanan Cell Phone: 978-239-5741 Emergency Telephone Numbers: FIRE POLICE RESCUE/AMBULANCE Call 911 Center: 1 MA Poison Control -800-682-9211 Hospital: Name: North Shore Medical Center (North Shore Children's Hospital) Phone: 978-741-1215 (Main Number) (978-745-2100) Address: 81 Highland Ave. Salem, MA 01970 (57 Highland Ave.) r Health Examination and Insurance Each student is required to provide a signed health form and a current immunization record before the start of the program in which they participate. Without these forms, 'the student will not be allowed to participate in the program. Procedures for Utilizing First Aid Equipment • Location of First Aid Kit: On-site at all times — in cottage, top drawer • Location of First Aid Manual: in Kit • First Aid administered by: Ryan Buchanan • First Aid Kit maintained by: Ryan Buchanan • Contents of First Aid Kit: in Kit Keri Cahill, Artistic Director P.O. Box 847 Salem, MA 01970 978-239-5741 RebelShakespeare@gmail.com The RebelShakespeare Company Medical Policy and Procedure: Upon enrolling students, parents are asked to provide detailed information concerning each child's health, including chronic illness or conditions, allergies, susceptibility to disease or injury, any learning disabilities, and any other medical considerations. Copies of these forms are kept confidential and on-site. In the event of an emergency involving a student, every effort should be made to contact the student's parent/guardian or other assigned contact person at the first opportunity, and contact efforts should persist until contact has been made. Procedures for reporting serious injury, in-patient hospitalization, and/or death of student or staff person to the Department of Public Health: • Health Care Supervisor should fill out DPH "Camper Injury Report" in consultation with Health Care Consultant and send to address on bottom of Report within 7 days of occurrence. Procedures for informing parents when first aid is administered to their children, including time frame and documentation • Parents/Guardian should be notified immediately if possible, but no later than the end of program day, when first aid is administered to a student. Keri Cahill, Artistic Director P.O. Box 847 Salem, MA 01970 978-239-5741 RebelShakespeare@gmail.com The RebelShakespeare Company Discipline Policies , • Corporal punishment, including spanking, is prohibited. . • No student shall be subjected'to crude or severe punishment, humiliation or verbal abuse. • Disciplinary action may only be handled by senior staff. • In the ordinary course of the program, no student should be sent home for a disciplinary problem. If extreme disruption and/or unique circumstances require the immediate removal of a student from the program, parent/guardian or other contact person must be notified and must pick up student and must sign-off on an "Early Release Form". The Artistic Director must be notified by the end of the day. • A record should be kept of student misbehavior, noting date, time and students/staff involved in the incident • Consistent problems with a student should be referred to the Artistic Director. Reporting of suspected child abuse • All staff shall immediately report any suspected child abuse or neglect. The report shall be made either to the Massachusetts Department of Social Services or the Artistic Director. • The Artistic Director shall immediately report suspected abuse or neglect to the Massachusetts Department of Social Services. • The Artistic Director shall notify the board of health if a 51A report alleging abuse or neglect of a child while in the care of the program or during a program related activity is filed. The 5 1 A report itself shall not be forwarded to the Board of Health. Keri Cahill, Artistic Director P.O. Box 847 Salem, MA 01970 978-239-5741 RebelShakespeare@gmail.com Theebel ha eareom C .es an �- S i p p y Medical Considerations Protection from the Sun All students are encouraged to apply sunscreen before they arrive in the morning. Students are also reminded at lunch time to re-apply sunscreen. If a student does not have sunscreen and circumstances require is, we have parental permission to put sunscreen on the camper. Minor Injuries Please consider any wound infectious. Latex gloves are provided in the First Aid Kit and should be used when treating the wound and cleaning the area. Major Injuries If a child is injured, loses consciousness, appears to have a broken or sprained limb, or exhibits any other medical emergency, do the following: 1. The first staff member on the scene stays with the injured person and calls loudly for help. Do not move the injured person. 2. The nearest staff member responds and goes to the aid of the injured person and staff member, at the same time dispatching a staff member to summon Ryan Buchanan. Other staff members gather the nearby students and quietly guide them away from the scene. 3. The directors assess the situation. If necessary, call 911, giving: Your name, location, nature of the emergency, location of the injured person on the property; quickest access to injured person. If it is not necessary to call 911, then the director will try to contact the injured student's parents/guardian. If we are unable to get in touch with them, Ryan Buchanan will take the child to his/her physician, as specified on the information sheet. All injuries, no matter how small, should be reported to the parents during pick-up. If serious, Ryan will contact them before then. Keri Cahill, Artistic Director P.O. Box 847 Salem, MA 01970 978-239-5741 RebelShakespeare@gmail.com The RebelShakespeare Company Communicable Disease Please let Ryan know if you see any sign of illness in which fever, rash, diarrhea, sore throat, vomiting, or jaundice is evident. The child should be isolated and we will notify the parents. If there is an unusual prevalence in the camp, we are required to notify the Board of Health. If a camper comes in sick, please bring that child to Ryan. We will contact the parent/guardian and ask that the child be brought home. If we are not able to contact the caregiver of the child, then we either revert'to emergency procedures or keep the child isolated until the end of the camp,day. Medications Students' prescription medication should be kept in a secure area and only administered by Ryan Buchanan. No student should take medication unsupervised or have medications in their backpack. Parents are required to sign a medical release before we are allowed to administer the medication. Pain I. Type: be specific; help children describe (sharp, dull, aching, stabbing) 2. Location: localize pain: "point with one finger to where it hurts" 3. Severity: how does it affect the child's behavior; does it interfere with play, eating, and anticipated activities? 4. Duration: how long does it last, when does it start and when does it occur? Nosebleed Have child sit up and lean forward. Apply continuous pressure to nose with thumb & forefinger for at least ten minutes. Apply ice or cold cloth to bridge of nose if bleeding. Avulsed tooth If the tooth is dirty, rinse it under running water or saline. Insert the tooth back into the socket, have child maintain tooth in place. If the child is resistant to reimplanting the tooth, place the tooth in cold milk. Transport the child to his/her dentist immediately. If the tooth is replaced within 30 minutes there is a 70% chance it will become reattached. Keri Cahill, Artistic Director P.O. Box 847 Salem, MA 01970 978-239-5741 RebelShakespeare@gmail.com The RebelShakespeare Company Eye Injuries Foreign Object: Remove freely moveable object with pointed corner of a slightly wet gauze pad. Caution the child against rubbing the eye. If object is lodged or eye is visibly injured in any way, child should be-immediately taken to his/her physician or the Emergency Room. Chemical Burns Irrigate eye copiously with tap water for 20 minutes. Pull out upper lid to flush thoroughly. Hold the child's head with eye under running tap (lukewarm) water. Take to Emergency Room and rest with eyes closed. "Black Eyes": Examine for visual disturbance and apply ice. Penetrating injuries: Take the child to the Emergency Room. Do NOT remove the object. Apply a patch over the unaffected eye . Maintain rest with head elevated. WITH EYE INJURIES: WHEN IN DOUBT, TAKE TO EMERGENCY ROOM OR CALL 911 IMMEDIATELY. Allergic Reactions Monitor child for hives and difficulty breathing. Call 911, contact emergency care. Keep child flat with legs raised about level of heart. Head Injury J r3' Stabilize the child's spine after head injury, especially if you suspect neck injury. Seek medical attention if the injury was caused by significant force or the following symptoms occur: 1. If child is unconscious (remember the length of time unresponsive) 2. Discomfort (crying) for more than 10 minutes after injury 3. Headache 4. Vomiting three or more times 5. Confused/odd behavior 6. Difficulty speaking or blurry vision (seeing double) 7. Unsteady gait 8. Neck pain 9. Fixed pupil IO.Bleeding from nose or ears (also watery discharge) Keri Cahill, Artistic Director P.O. Box 847 Salem, MA 01970 978-239-5741 RebelShakespeare@gmail.com The RebelShakespeare Company Hypoglycemia (low blood sugar) This can occur rapidly and the child is often his/her own "expert" in this area. Possibly symptoms: irritable/weepy, feeling shaky, dizzy, complains of a headache, pale and sweaty, glucose is below 60 mg/dl. Burns Minor Burns Stop the burning process. Apply cool water to burn or hold burned areas under cool running water. Do not disturb any blisters that form. Do not apply anything to the burn. Cover with a clean cloth. Remove any burned clothing or jewelry that is near the burned area. Major Burns Stop the burning process. Smother fire and roll victim in blanket. Assess airway and breathing. Choking Use Heimlich maneuver. Vomiting This is often a sign of respiratory infection, ear infection, etc., in younger children. The child should ingest nothing by mouth for 10-15 minutes then take sips for clear fluids. Keri Cahill, Artistic Director P.O. Box 847 Salem, MA 01970 978-239-5741 RebelShakespeare@gmail.com Love's Labour's Lost Contact List 2014 ACTORS Danny Abrams 781-631-0492 Anya Bachman 978-741-7589 Will Barth 978-979-1101 Aubrey Clark 781-307-1884 Will Curtis 781-631-7904 Melanie DeRoiser 978-660-7112 Eva Ducroux 978-210-2862 Martin Ducroux 978-210-2862 Gabe Gonzales 617-642-7667 Juliet Giangregorio 978-609-0863 Madeleine Holtz 978-395-5480 Eliza Jane Holtz 978-395-5480 Sarah MacRae 781-593-1685 Aidan Merriam 508-735-5810 Jeffrey Miller 978-968-9477 Olivia Moore 978-395-1645 Drew Pelrine 781-248-0126 Nick Pocharski 781-502-6962 Sarah Ricker 781-254-5496 Will Ricker 781-254-5496 Catherine Smith 732-690-8072 Alice Sullivan 781-596-2660 Lucy Tuttle 978-740-4555 Izzi Warner 617-416-0361 Jemma West 978-337-4671 Laetitia West 978-337-4671 DIRECTORS Ryan Buchanan 978-394-4372 ryan.buchanan2@gmail.com Keri Cahill 978-239-5741 kericahi1134@gmail.com Maeve Harrington 978-395-6797 maevekh@gmail.com Isabelle Rabin 978-290-6838 dizzyizzy819@gmail.com Annie Seminiara 617-538-7560 aseminara@exeter.edu „ Heartsaver® American ? ! CPR A E D Heart training When Seconds Count,Inc” ID a MA20278 Association. Center Name TC PO Box 3002 Info .,Salem,MA 01970 (978)744-4799 Adelaide Majeski _ This card certifies that the above individual has successfully completed the objectives Course and skills evaluations in accordance with the curriculum of the AHA Heartsaver CPR AED Location When Seconds Count Training Centef Program.Optional completed modules are those NOT marked out Instructor Inst.ID If - Child CPR AED Infant CPR WHAOR46t Name_ -__ Ashley Turner _(03112356839) 06-11-2013 06-2015- -------- —-------- ------ Issue Date Holder's Recommended Renewal Date Signature 020tt gmencan Hearl Auxietion Tampeli,g wiM Mis card will aYa'ifa appgalenre. 9p1012 I y . r a a + '" raining When Seconds Count,Inc. TC ID s MA20278 Heartsaver® American Center Name _------- First r s t A I � Heart r J L Association. Tc .,_ Salem,MA 01970; (978)744-4799 Info —. — — Adelaide Majeski Course When Seconds Count Training Center This card certifies that the above individual has successfully completed Inst0�12356839) he objectives and skills evaluations in accordance with the curriculum of Instructor Ashley Turner ( the AHA Heartsaver First Aid Program. Optional Module completed if NOT marked out: Written test - ---- 06-13-2013 06-2015 Holder's ----------- Signature ___— ------ Issue Date Recommended Renewal Date , o zoll anenrz.Haan asaaciation ra wmrm wim rrvs card.al atrell¢appPsarma. eo-1e1a STATE SANITARY CODE: CHAPTER IV,MINIMUM SANITATION AND SAFETY STANDARDS FOR RECREATIONAL CAMPS FOR CHILDREN 105 CMR 430.000 1 RECREATIONAL CAMP FOR CHILDREN INSPECTION REPORT _ NAME OF CAMPpitQQ, � f� ADDRESS: OWNER/OPERATOR: OFF SEASON ADDRESS: CAMP DIRECTOR: INSPECTED BY: TYPE OF CAMP: (Circle) WATER SOURCE: DATE AND TIME OF INSPECTION: Day Residential (Sport/Non-Sport) Trip Primitive Travel CAMPER CAPACITY: ACCOMPANIED BY: Swimming Pool:Yes No VGB Compliance Letter: Yes No "No"column marked below indicates a violation of 430.000. "Yes"column marked below indicates compliance with provision of 430.000. "N/A"column= "1l"marked below indicates that the provision of 430.000 is not applicable to this camp. R tion Yes No N/A Comments Permits .451 Current Certificate(s)of Occupancy from local building inspector for sleeping/assembly areas .215 Written compliance from local fired t .633 Camp license posted in prominent location .300(A)(2)(a) Private water supply-DEP approval(>25 _people,>60 da s/ y Yr) .300(A)(2)(b) Private water supply-BOH approval and chemical and bacterial analyses (<25 people,<60days/yr) Plans and Policies-Written .090(A) Procedures for background review of staff and V volunteers(Available/Followed) .090(C) CORI and SORI,previous work history, ✓ 3 references,out of state/international criminal background checks for staff .090(D) CORI and SORI,previous work history, / 3 references,out of state/intemational criminal V/ background checks for volunteers -Crrs(paying campers or unpaid volunteers .090(E) Back ound information maintained for 3 years .090(F) Received,reviewed, and made determination J in regards to all background information .091 Staff and volunteer orientation plan and review .093 Abuse and neglect prevention/reporting V/ procedures .191(13)(C) Discipline Policy with: appropriate discipline methods and prohibitions .210(A) Fire evacuation plan and drills -Drills conducted within the first 24 hours of each session .210(B) Disaster Plan -including information on transportation 430-Rec Camp-Inspection Notes-Revised 8-20-10 Page 1 of 12 R ation Yes, No N/A Comments .210(C) Lost Camper Plan .210(C) Lost Swimmer Plan .210(D) Traffic Control Plan ✓ Contin ency plans-Day Camp: .211 (A Camper doesn't show up for cam (B) Camper doesn't show u at point of pick u (C) Child not registered arrives Contingency plans-Primitive,Travel and Trip: .212 A Itinerary daily-coy provided to parents (B) Source of emergency care Camper release: .190(B) Camper released only to parents or parent- designated individual in writing -Other plan- approved in writing by BOH Promotional Literature and Informational Packets .159(B)(2) Copy of policy re: care of mildly ill campers, administration of meds and emergency health care provision 190(C) Statement re: regulatory compliance and V licensing .190(D) Inform parents of right to review background ✓ check,health care,discipline policies and grievance procedures upon request Transportation .250 Vehicle must comply with MGLc.90 s7B&7D: <14 passengers and driver is camp coach, director, etc.private vehicles may be used f >14 passengers,vehicle must be school bus All vehicles must be RMV compliant .253 Proper automobile insurance .251(C)(F) Seatbelts must be wom and special needs of campers communicated to driver .251(I-I) Camper<7yrs not transported longer than 1 hr ✓ to or from cam Staff Qualifications Camp Director: .102(A) Residential Camp: 25 yrs,completed course in f camp administration or at least 2 seasons of ex enence .102(B) Day Camp:21 yrs,completed camp administration course or 2 seasons of experience .102(C) Primitive,Travel,Trip: 21 yrs and proof of ex enence .102(D) Designated substitute when director off-site>12 fzyp,VL U G1CmOo., hrs -Sub must meet criteria above 430-Rec Camp-Inspection Notes-Revised 8-20.10 Page 2 of 12 R lation Yes No N/A _—Comments- Counselors/Junior ommentsCounselors/Junior Counselors: .100 Day camps,non-sport: V Counselor=l6 yrs. Junior Counselor-15 yrs. .100 Other camps: Counselors= 18 yrs or graduated from high school. Junior Counselors= 16 yrs .100 All counselors 3 yrs older than campers Required Counselor Ratios: .101(A) Residential and Day Camps: I staff per 10 kids over 6 yrs 1 staff per 5 campers 6 yrs and under .101(B) Primitive,Travel,Trip: I counselor per 10 campers. 2 counselor min .101(C) Special Needs: I counselor per 4 mildly disabled campers 1 counselor per 2 severely disabled campers .103 Aquatics Director: Name None American Red Cross Lifeguard Tmg cert,CPR ✓ for Professional Rescuer and First Aid Cert.or their equivalents -If supervise 2 staff,21yrs and experience w/mana ement .103 Lifeguard:American Red Cross Lifeguard Tmg cert.,CPR for Professional Rescuer cert. and First Aid Cert. or their equivalents -List names .103 Certifications for other high-risk activities, eg: NRA instructor certification for firearms. -List Names and Certifications: .252 Camp vehicle drivers: 18yrs,2yrs driving experience,current license for type of vehicle -First Aid certified if no other trained staff aboard Medical Personnel Records and Facilities .159(A) Health Care Consultant, e: IL W War NP PA(w/pediatric training) ense#: 77 & Check for Health Care Consultant Agreement • Review and approve first aid training of staff • HCC available for consolations at all times • Si ed written orders for HS .159(C) Health Supervisor(on site at all times) Name: "qfl in f<vrli a vl .C' 18yrs, Fist AN and CPR certified OR, MD PA NP RN LPN EMT -special needs or residential with>150 staff and campers must have health professional .159(B) Health Care Policy • Approved by LBOH and HCC • Policy provided to all full time staff during orientation 430-Rec Camp-Inspection Notes-Revised 8-20-10 Page 3 of 12 R lation_ _ Yes No N/A Comments .160(A) Medication stored in original containers .160(B) Meds stored in secured cabinet and if necessary refrigerated in box affixed to refrigerator(if no secondary lock) • Cabinet used for no other purpose • Refrigerator temperature 38 to 42T .160(C) Medication administered by Health Supervisor • HCC written acknowledgement of all medications administered at eh camp(if HS is not MD PA NP RN LPN) • Written premising from parent/guardian .154 Injury Reports completed for fatality or serious �. injury. Copy sent to MDPH within 7 days .155 Medical log book-bound,pre-numbered pages, ink entries,no skipped lines .161(A) Infirmary provided-day and resident camps / • Clearly Labeled as Infirmary/Medical Area • Exterior light residential Camps) .453 Lighting rovided in infirmary .161(B) Area for isolation of ill child-Residential Camps • Not used for any other purpose .161(C) First Aid Kit: non-perfumed soap,sterile gauze , / squares,compresses,adhesive tape,bandage scissors, V triangular and rolled bandages,CPR mask,tweezers,cold pack,gloves. .150 Health record for each camper and staff: Number of records checked: -emergency contact info -camper<18 yrs must have written parental Number of med/care -Permission for meds and emergency care Residential Sport,Travel/Trip: penmssions mssng: -Health History,Physical Exam(<2yrs) -Record of Immunizations(noted below) Day Camp Non-Sport: Number health history/exam -Health History signed by parent/guardian or physician missing: -Record of Immunizations(noted below) Immunizations: .152(A) Campers and staff under 18yrs: Number of records checked: -MMR I'dose= 12 mos or older, -Measles:2"d dose—grades K-12 or age equiv Vaccination records missing: -Polio: 3 doses IPV or OPV, or 4 doses mix IPV/OPV -Diphtheria,Tetanus Toxoids,and Pertussis*: 4 doses DTaP/DTP/DT or, Number of missing 3 doses of Td Campers and Staff>7 years *Booster dose of Td: Number of missing -grades 7-10 need booster if>Syrs since last dose of DTaP/DTP/DT -grades I 1-12 need booster if more than 10 yrs Number of missing since last dose of DTaP/DTP/DT/rd He B: 3 doses if born on or after 1/1/92 430-Ree Camp-Inspection Notes-Revised 8-20-10 Page 4 of 12 R_ lation Yes No N/A Comments _ .152(B) Campers and staff 18 yrs or older: Number of records checked: -Measles:2 doses(exempt if bom before 1957) -Mumps: 1 dose (exempt if born before 1957) Vaccination records missing: -Rubella: 1 dose (exempt if bom before 1957) D -Diphtheria and Tetanus Toxoids*: 3 doses DTaP/DTP/DT/Td Number of missing *Booster dose of Td: O -If more than 10 yrs since last dose ll Number of missing V Activities .190(A) Activities and physical environment meet the needs of campers; do not pose hazard to health and safety .163 Operator encourages sun protection for all Aquatics: .430 Swimming Pool: in compliance with 105 CMR 435.00 -pennit posted .204(B) Bathing Beach: in compliance with 105 CMR 445.00 -weekly water sampling conducted/available .103 Proper supervision at swimming venue: 1 lifeguard per 25 campers 1 counselor per 10 campers -Plan to check swimmers-"buddysystem" .204(A) Swimming areas clean and safe,no swimming at undesignated sites or at night without lighting .204(C) Swim test to classify swimmers by ability .204E Piers and floats in good repair .204(G) Watercraft: equipped with US Coast Guard approved flotation devices and worn by all campers and staff participating in watercraft activities .204(H) Campers must be certified by American Red Cross or equivalent for white water,hazardous salt or fresh water activities .103(C) Minimum 2 counselors in separate watercraft supervising white water,hazardous salt or fresh water activities Arts and Crafts: .205 Equipment in good repair,safety precautions taken Playground and Athletic Equipment: .206 Equipment properly maintained,fields/surfaces free of holes/accident hazards .206 Playground equipment secure,no concrete under/around it,pliable swing seats 430-Rec Camp-Inspection Notes-Revised 8-20-10 Page 5 of 12 R lation Yes No N/A_ Comments_ Horseback Riding: .208(A) 1 certified instructor per 10 campers(Min.2 counselors) .208(A) Riders must wear hard hat .208(B) Licensed stable Firearms: .201 Single shot rifles only .201 Shooting range away from other activity areas .201 Firearms in good condition,stored in locked cabinet.Ammunition locked in separate cabinet Archery: .202 Equipment in good condition, stored in locked area .202 Range away from other activity areas,clearly marked as danger area. Must have common thing line and 25 yards clearance behind targets .203 No personal weapons,bows,rifles allowed Cabins Structures,and Facilities All Structures: .216 Smoke detectors provided in all structures .453 Lighting provided in: -kitchen and dining room -toilet rooms -stairways .454 Floors maintained in all structures .455/.456 Egresses comply with Bldg. Code and are free from obstruction Day Camp Shelters: .457 Day Camp provides shelter for on-going camp activities Residential Camps-Sleepft Areas: .452 Screens and self-closing screen door provided .458 Provide adequate space: 40sgft/person in single bed 35sgft/person in bunk bed - -50sqft/person in sleeping area requiring cial equipment .459 Campers and staff with limited mobility housed on ground level with egresses leading to grade or ramp provided .470 Bed or cot provided to each person with: -6 feet between sleeper's heads -3 feet between single beds or 4'rz feet between bunks -Triple bunk beds are prohibited Tents: .217 Fire-retardant and non-toxic -No open flame nearby .458 35 ft/ erson in tent Toilets and Showers: .301 Plumbing in good working order .302 Cross-connections 430-Rec Camp-Inspection Notes-Revised 8-20-10 Page 6 of 12 Relarullation Yes_ N_o N/A Comments .360 Proper sewage disposal .370 Adequate#of toilets: -All camps:2 toilets/privy seats for each gender -Day Camp:>60 of one sex,provide 1 additional toilet per every 30 people of that gender -Non-Day Camp:>20 of one sex,provide 1 additional toilet per every 10 people of that gender .373 Adequate#of sinks: -Day Camp: 1 per every 30 people -Residential Camp: 1 per every 30 .374 Adequate#of showers: -Residential Camp: 1 shower or tub per 20 people .375 Toilets and shower rooms ventilated to exterior .376 Hot water at sinks, showers,or tubs not more than 112°F .377 Sanitary facilities maintained in clean condition- Shower room floors washed daily .378/.380 Special needs campers provided facilities that meet their needs Laundry .162 Residential Camp: Laundry facilities provided .472 Bedding and towels laundered;no common towels,sheets washed every 7 days,sleeping bas aired out every 5 days Grounds .165 Tobacco use restricted to designated areas not accessible to campers .207 Proper storage and operation of power equipment .209 Telephone readily available: -with emergency contact number posted:HCC,EMS, police,fire -Day and Residential Camps only .213 Emergency communications stem .214(A) Flammable and hazardous materials labeled and stored in locked unoccupied building 214(B) Storage of cleaning and other chemicals .300 Potable water provided .300/.304 Adequate and centralized drinking water facilities -No common drinking cups .350/.355 Proper storage and disposal of solid waste .400(A) Rodent and insect infestation .400(B) Rodent and insect control plan: -Proper extermination method .401(A)(B) Weed and noxious plant control .450(A)(D) Site location does not cause undue traffic hazards and is accessible at all times .450(B) Site location not located where surface drainage conditions create no health or safety,hazard 430-Rec Camp-hispection Notes-Revised 8-20-10 Page 7 of 12 Regulation Yes No N%A Comments Food Service --- — — --- .320 Food service in compliance with 105 CMR 590.000,Minimum Standards for Food Establishments. Permit posted in food service facility .330 Nutritious meals that include a variety of foods served. Menus posted .331 Residential camps—Provide at least three nutritious meals. Foods must meet Recommended Dietary Allowances(RDA) .332 Day camps—Each meal provided must meet 1/3 of the RDA requirements .334 Adequately trained staff and equipment provided to ensure handicapped campers are eating nutritious meals .335 Proper methods for storing meals brought from home. Meals provided to campers who arrive without a bag lunch .452 Screening provided for food preparation and food service areas. Screen doors must be self- closing .453 Lighting rovided in kitchen and dining area .471 Sleeping rohibited in food areas REGULATION NO. THE SPACE BELOW DESCRIBES VIOLATIONS MARKED ABOVE 430-Rec Camp-Inspection Notes-Revised 8-20-10 Page 8 of 12 430-Rec Camp-Inspection Notes-Revised 8-20.10 Page 9 of 12 430-Rec Camp-Inspection Notes-Revised 8-20-10 Page 10 of 12 430-Rec Camp-Inspection Notes-Revised 8-20-10 Page 11 of 12 430-Rec Camp-Inspection Notes-Revised 8-20-10 Page 12 of 12