GMC Camps COVID-19 Certificate of Compliance

All guests in your party must fill out the form below on the morning of arrival, so please fill it out before you leave your house to go to the camp. The form cannot be filled out prior to the date of your arrival. Filling out the form below is the only way to submit your certificate of compliance. We are not accepting mail-in or emailed responses.

Reservation Information
In which camp are you staying?*
Date of Arrival*
Must be today's date. Please do not fill out this form on a date prior to your start date.
MM slash DD slash YYYY
Name of person who made the reservation*
If someone other than yourself made the reservation, please enter their name. If you made the reservation, please enter your name.
First Last
CERTIFICATE OF COMPLIANCE
TO VERMONT BE SMART, STAY SAFE EXECUTIVE ORDER 01-20
1. I certify that: a. I am a critical worker as defined by the State of Vermont; OR b. I have not left the state of Vermont for any reason except essential travel in the past 14 days; OR c. I have been in a county in CT; MA; MD; ME; NH; NJ; NY; OH; PA; RI; VA; Washington, D.C.; or WV with fewer than 400 active COVID-19 cases per million, as set forth on the Vermont Agency of Commerce and Community Development’s website*, and I did not travel to Vermont by air or bus; OR d. I have traveled to Vermont from another state, and I traveled directly from my home in my personal vehicle, and I have completed a 14-day self-quarantine (or a 7-day self-quarantine followed by a negative test result) in that state; OR e. I have traveled to Vermont from another state, and I will complete a 14-day self-quarantine (or a 7-day self-quarantine followed by a negative test result) in Vermont at a lodging establishment or residence, and I acknowledge that I must stay in my quarantine location for the duration of the quarantine.*
1. I certify that:
a. I am a critical worker as defined by the State of Vermont; OR
b. I have not left the state of Vermont for any reason except essential travel in the past 14 days; OR
c. I have been in a county in CT; MA; MD; ME; NH; NJ; NY; OH; PA; RI; VA; Washington, D.C.; or WV with fewer than 400 active COVID-19 cases per million, as set forth on the Vermont Agency of Commerce and Community Development’s website*, and I did not travel to Vermont by air or bus; OR
d. I have traveled to Vermont from another state, and I traveled directly from my home in my personal vehicle, and I have completed a 14-day self-quarantine (or a 7-day self-quarantine followed by a negative test result) in that state; OR
e. I have traveled to Vermont from another state, and I will complete a 14-day self-quarantine (or a 7-day self-quarantine followed by a negative test result) in Vermont at a lodging establishment or residence, and I acknowledge that I must stay in my quarantine location for the duration of the quarantine.
I agree
2. I also certify that I have not had close contact within the past 14 days with a person confirmed to have COVID-19.*
2. I also certify that I have not had close contact within the past 14 days with a person confirmed to have COVID-19.
I agree
3. I also certify that I do not currently, and have not had in the past 24 hours, any of the following symptoms: • Cough; • Difficulty breathing; • Fever (feeling feverish or have a measured temperature at or above 100.4°F/38°C); • Used a fever reducer (in the past 24 hours, have you used any medicine that reduces fevers?); • Chills; • Repeated shaking with chills; • Muscle pain; • Headache; • Sore throat; • New loss of taste or smell.*
3. I also certify that I do not currently, and have not had in the past 24 hours, any of the following symptoms:
• Cough;
• Difficulty breathing;
• Fever (feeling feverish or have a measured temperature at or above 100.4°F/38°C);
• Used a fever reducer (in the past 24 hours, have you used any medicine that reduces fevers?);
• Chills;
• Repeated shaking with chills;
• Muscle pain;
• Headache;
• Sore throat;
• New loss of taste or smell.
I agree
4. I also certify that all persons in my care who are under the age of 18 or who are dependent on my care meet the criteria described in items 1–3 above. Please provide a list of the names of all such persons in your care.*
4. I also certify that all persons in my care who are under the age of 18 or who are dependent on my care meet the criteria described in items 1–3 above. Please provide a list of the names of all such persons in your care.
I agree
Dependent #1 Name
First Last
Dependent #2 Name
First Last
Dependent #3 Name
First Last
Dependent #4 Name
First Last
Dependent #5 Name
First Last
Dependent #6 Name
First Last
Dependent #7 Name
First Last
Dependent #8 Name
First Last
5. By way of this form, I have been informed that out-of-state guests are encouraged to register with the Vermont Department of Health’s Sara Alert system and to provide updates to that system daily.*
5. By way of this form, I have been informed that out-of-state guests are encouraged to register with the Vermont Department of Health’s Sara Alert system and to provide updates to that system daily.

I agree
6. I have read and understand this entire Certificate of Compliance and make the above certifications under the pains and penalties of perjury. *For information related to completing this form, visit: accd.vermont.gov/coc*
6. I have read and understand this entire Certificate of Compliance and make the above certifications under the pains and penalties of perjury.

*For information related to completing this form, visit: accd.vermont.gov/coc
I agree
Today's Date*
Reminder: You must fill this out on the start date of your stay. You cannot fill it out in advance.
MM slash DD slash YYYY
Town Where You Completed This Form*
City State / Province / Region Country
Person 1
Person 1 Signature*
Person 1 Name*
First Last
Person 2 (From same household; optional)
Person 2 Signature
Person 2 Name
First Last
Household Contact Information
GMC is required by the state of Vermont to main a log of renters and their contact information in the event contact tracing is required by the Health Department.
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone*
Email*
CAPTCHA

GMC Camps COVID-19 Certificate of Compliance

Reservation Information

CERTIFICATE OF COMPLIANCE

Person 1

Person 2 (From same household; optional)

Household Contact Information

Mission

Featured Sponsors

Connect