Montgomery County Department of Health and Human Services

Licensure and Regulatory Services

255 Rockville Pike, Suite 100; Rockville, Maryland 20850

Phone: 240-777-3986    Fax: 240-777-3088

www.montgomerycountymd.gov/licensure

 

RECREATIONAL CAMP/SUMMER CAMP PROGRAM APPLICATION

Application is hereby made for a license to operate a Recreational Camp/Summer Program in Montgomery County, Maryland.

 

r New   r Renewal                                                                                    TODAY’S DATE____________________

Name of Camp/Program: _________________________________________________________________________

Address: ______________________________________________________________________________________

                                             (Location of camp)            Street Number and Street Name

___________________________________________________________________Telephone #: ________________

                                             City                                     State                                   Zip Code                                     Include Area Code

Owner or Corporation Name: ______________________________________________________________________

Mailing Address_______________________________________________________________________

                                                                                        Street Number and Street Name _______________________________________________________                                             Federal Tax Identification # ­­_______________

            City                                    State                                     Zip Code                 

 

Camp Director's Name: __________________________________________Telephone #: _____________________

                                                                                                                                                                     Include Area Code

Person to contact and daytime phone number to arrange inspections:

Contact Person's Name:_________________________________  Daytime Telephone:________________________

                                                                                                                                                                Include Area Code

Fax Telephone:________________________   Email Address:___________________________________________

                                Include Area Code

Maximum number of children at any time: _____________                Number of children enrolled: ________________

Do you intend to prepare/serve meals on the premises?-------------     r yes                                 r no

Do you have a swimming pool on the premises?---------------------       r yes                                 r no

Has all staff had a criminal background check?-----------------------       r yes                                 r no

Water Supply: r  public   r  private                                                       Sewerage: rpublic     r  private

Dates of Operation:  Open                                     Close                                     

Is this location currently licensed as a Day Care Center under COMAR 07.04.02? r yes r no

        Note:  New Camp or Change of Location for an existing camp a copy of your Use and Occupancy Permit for school

        or day care use must be attached to this application.  To obtain a Use and Occupancy Permit call 240-777-6240.

 

Signature:__________________________________________________________  Title:______________________

 

 

OFFICE USE ONLY

Receipt Number:  ______________                                                                                                Date Issued:  _______________

Amount Paid:  _________________                                                                              Date Expires:  ___

Check/Money Order Number:  ______________                                                         Record Number:  ___________

 

Payment Method        Fee Information:  See Fee Schedule.

r  Check   r Money Order (No cash is accepted)  r Visa   r  MasterCard  (No other credit cards are accepted)

Organization: _________________________________Cardholder’s Name:______________________________

Credit Card No:_________________________________ Exp. Date:______________  Amt: $_______________

I agree to pay the above total amount according to the card issuer agreement.­­­­­­­

 Cardholder’s Signature: _______________________________________________________

 

Submit completed application and application fee to address at the top of the application. Checks or money orders are payable to “Montgomery County, Maryland”.