Camp and Program Emergency Plan Form – Risk, Safety, & Resilience

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General Information

Name of Person Completing This Form(Required)

First Last

Email for Correspondence Regarding this Form(Required)

Camp / Program Name(Required)

Sponsoring Organization (if applicable)

Camp Administrative Address(Required)

Street Address Address Line 2 City State ZIP Code

Camp Director(Required)

First Last

On-Campus Supervisor(Required)

First Last

Camp Begin Date(Required)

MM slash DD slash YYYY

Camp End Date(Required)

MM slash DD slash YYYY

Has this camp been previously hosted at George Mason University?(Required)

Yes

Years in Operation(Required)

Camp / Program Type(Required)

On-Campus Camp Location(s)

On-Campus Location (Building / Field Name)(Required)

Use the (+) symbol to add additional locations. Please list all on-campus locations associated with this camp or program.

Emergency Contacts

Some contacts have been pre-populated. Please add any additional contacts for your camp / program emergency contact list.

Role / Contact Type	Name / Office	Phone	Email
University Police (24/7)	GMU Police	703.993.2810	[email protected]
Fire / EMS	George Mason Emergency Medical Services	9-1-1	N/A
Risk, Safety, and Resilience On-Call Number	Emergency Management and Fire Safety	703.993.7233	[email protected]
Risk, Safety, and Resilience	Emergency Management and Fire Safety	703.993.8448	[email protected]

Camp Director(Required)

Name

Phone

On-Campus Supervisor(Required)

Name

Phone

On-Campus Health Supervisor(Required)

Name

Phone

George Mason Camp Point of Contact(Required)

Name

Phone

Additional Emergency Contacts(Required)

Use the (+) symbol to add additional locations. Please list all on-campus locations associated with this camp or program.

Role / Contact Type

Name / Office

Phone Number

Emergency Preparedness and Resources

Please answer each question below. Refer to the below linked resources as needed:

AED and Emergency Supplies Locations On Campus
Mason Alert Emergency Notification System

Where is the closest Automated External Defibrillator (AED) located?(Required)

AED and Emergency Supplies Locations On Campus

Where are the nearest emergency supplies stored?(Required)

Where is the nearest fire extinguisher stored?(Required)

Will the camp utilize additional Emergency Equipment?(Required)

Yes

If yes, please explain.(Required)

Does the designated On-Campus Health Supervisor hold a current CPR/First Aid Certification?(Required)

Yes

Will the On-Campus Health Supervisor have a First Aid kit readily available?(Required)

Yes

How will emergency information be communicated to staff?(Required)

(e.g., radios, PA system, text alerts, WhatsApp)

What method will be used to notify campers of an emergency, also referred to as the “Camp Emergency Alarm”?(Required)

(e.g., PA system, whistle, foghorn)

What method will be used to notify parents/caregivers in an emergency?(Required)

(e.g., email, text message, phone call)

Camper Pick-up / Drop Off Location(Required)

Alternative Pick-up / Drop Off Location(Required)

Is the Camp Director, On-Campus Supervisor and On-Campus Health Supervisor enrolled in Mason Alert?(Required)

Mason Alert Emergency Notification System

Yes

Please ensure enrollment prior to the start of Camp.

Emergency Response Roles and Responsibilities

Note: The On-Campus Director is responsible for any task not assigned to another member of their staff.

Sound the Camp Emergency Alarm(Required)

Primary Responsible Role

Back-up Role

Provide First Aid(Required)

Primary Responsible Role

Back-up Role

Initiate Camp Evacuation / Shelter In Place(Required)

Primary Responsible Role

Back-up Role

Conduct Search for Missing Camper(s)(Required)

Primary Responsible Role

Back-up Role

Notify Parents in Emergency(Required)

Primary Responsible Role

Back-up Role

Conduct Assembly Group Headcounts to ensure accountability:(Required)

Use the (+) symbol to add as many Assembly Group Leaders as needed.

Assembly Group Leaders

Are there additional tasks that must be performed during an emergency?

If yes, detail what the task is and who will perform it.

Assembly & Evacuation Locations

Please refer to Assembly Areas and Campmus Addresses

Assembly & Evacuation Locations(Required)

Use the (+) symbol to add additional rows for each group as needed.

Group Number

Assembly Area Description

Indoor Shelter-In Place Location for Emergency Situations

Use the (+) symbol to add additional rows for each group as needed.

Building Name

Room Number

Required Documentation & Acknowledgments

I have read and understand the Camp & Program Emergency Plan (CPEP).(Required)

I have read and understand the Camp & Program Emergency Plan (CPEP).

Yes(Required)

I understand my role and responsibilities in the event of an emergency.(Required)

I understand my role and responsibilities in the event of an emergency.

Yes(Required)

I will ensure that all camp staff are aware of emergency procedures, including evacuation and shelter-in-place protocols.(Required)

I will ensure that all camp staff are aware of emergency procedures, including evacuation and shelter-in-place protocols.

Yes(Required)

I confirm that the information provided in this document is accurate to the best of my knowledge.(Required)

I confirm that the information provided in this document is accurate to the best of my knowledge.

Yes(Required)

Signature(Required)

Your typed name below represents your signature on this document. Please ensure all information is accurate and complete prior to signing below and submitting this form for review.

First Last

Date(Required)

MM slash DD slash YYYY