Consumer, Environmental and Occupational Health Service
Public Health and Food Protection Program
P.O. Box 369 | Trenton, NJ 08625
ph: (609) 826-4935 | youthcamps@doh.nj.gov
https://nj.gov/health/ceohs/sanitation-safety/youthcamps.shtml
YOUTH CAMPS COVID-19 ATTESTATION FORM
The following are the minimum requirements for each Youth Camp Operator/Director and Health Director to document
and attest that their facility has developed, prepared, and is ready to implement a COVID-19 Youth Day Camp
Standards policies and procedures. Completion of this form is required by Executive Order 149 and must be completed
in full and mailed or emailed to the Department at least 24 hours prior to the anticipated opening date of the camp.
Save this form and email it as an attachment to: youthcamps@doh.nj.gov
Youth Camp Certification No.
Name of Youth Camp
Name of Youth Camp Operator/Director
Name of Youth Camp Health Director
Location Address
Location City/State/ZIP
Email Address
Y N Has your youth camp developed COVID-19 Youth Day Camp Standards policies and procedures?
Do your youth camp COVID-19 policies and procedures meet the following minimum standards?
Y N appropriate social distancing and/or face coverings
Y N hygiene practice, i.e. hand washing and face touching
Y N enhanced cleaning and disinfection
Y N
other public health prevention strategies such as but not limited to: cohort groups of
campers, staggering of arrival/dismissal, isolation of campers and staff, signs,
PPE’s, daily health surveillance, temperature screening at entry
Y N
Do you receive any grants or subsidies from the NJDHS?
If Yes:
# of Single Sport locations under this certification:
Camp Type (select all that apply)
Questionnaire: The following questions must be answered Yes or No. Please check “Y” for yes and “N” for no. All “No”
answers must be followed by a detailed explanation. (refer to New Jersey COVID-19 Youth Day Camp Standards
Guidelines document for more details posted at https://www.nj.gov/health/ceohs/sanitation-safety/ )
Indoor
Outdoor
A COPY OF THIS COMPLETED FORM MUST BE MAINTAINED ONSITE
$2,000 Emergency Child Care Assistance Program Grant CCR&R Child Care Subsidy Program
ATTESTATION: I certify that the information is true and to the best of my knowledge. I have read and will comply with
the COVID-19 Youth Day Camp Standards policies and procedures. My submission of this form constitutes an
attestation of compliance with the COVID-19 Youth Day Camp Standards policies and procedures.
Print Name___________________________________________ Title __________________________________
Signature _____________________________________________Date_________________________________
Y
N
Please explain any “No” responses in the space below. Attach additional sheets if necessary:
Are you a Local Education Agency, including school district, charter school, renaissance school,
Educational Services Commission, or joint commission?
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