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MONGER
SPORTS
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RECREATIONAL CAMP
L1C.ENSE APPLICATION ,
Camp Name: Challenger Sports..
Location. where camp operates. G ..
City: State:
ZIP Code;
Phone:
Fax: .
Email: rhabarak@cha.Ilengerspgrts.com
Website/Social Media address: www.challen e, .. g rs p... orts.comI '
,,.
• ® 0 1 0 i
111:11M 11
Owner/Organization Name:
Challenger Sports
Primary Mailing address: 94a Jeffersoh Blvd
City: WarwiCk State: Rl ZIP Code: 02888
Phone(year-round): 4017M-0465 Fax: 401-228-6548
Email:
ma.barak@challenger.sports.com.
send the license to this email address.
Director/Operator Name:. Yet to be decided
Primary Mailing address:
City:. State: ZIP Code:
Phone(year=round): Fax:
Email:
Esend
the.license to this email address
If the camp previously.operated in Massachusetts provide: year(s) the .camp operated and the names) the camp operated un"der ., ..
ElFrom:
To: Name(s):
N/A
Has the camp's license ever been suspended or revoked: (check):
Day or Residential Camp:
Suspended
Day
Revoked
Residential
Neither
Seasonal or Year-Round Camp:
Seasonal camp only:
Opening Date for camp: l�h
Seasonal
Closing Date for camp:
Year-Round
.
I j
Hours of Operation:tf1A� "I J1a11
Swimming Pool(s): Pool Permit Number:
Yes Off-site Off -Site Pools (if applicable):
El
N0
Total Number of Pool(s):
Bathing Beach(s): Names of lake or river located at camp (if applicable):
Yes 0 Off-site
No
Off -Site beaches (if applicable)
Meals Provided: F
FL.yJ'
Food Permit Number:
Yes No _
April 2018 Page's of
Camp Capacity (per Session)::. TBC
Campers: TBC Staff:
TBC
Total Number forttie.Yeat:. .
Name Mary Christina Simpson
MIA License. Number:.. 273-304.
Phdne (to reach.duririg camp operations) .401-787-8488.
Type Medical License
►of
Physician Physician. Assistant.
�^^
N( OTE.: Attach documentation LJ Other:.
Nurse Practitioner
of pediatric training if a PA)
Yet.to be decided
MA License Number:
Age:
Type of Medical License Registration or Training 105 CMR 430.159(C):
Physician Physician Assistant
Nurse Nurse Practitioner
�f { First Aid CPR AED
•` + Other: Please attach
documentation of current First Aid / CPR Training
Name:
Age:,
Lifeguard Certificate issued by:.
American Red Cross CPR Certificate:
L
Expiration date:
Exp,irati ate:
7AMeric-an First Aid Certificate: "i Previous aquatics supervisory experience:
Expiration date:
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�. -. .ation date:qui4
F'tT�''.
Number:License
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Stable
Licensed in acco rdance with MGL c.1 11 §1551
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April 2018 Page 3 of 3
CIONCER
SPORTS'
Page 5 of 87