Pre Trip Covid Self Certification Form - Standalone

Pre-Trip COVID-19 Self-Certification Form

Please note: This is a non-submittable sample form.

Please complete this form using the specific link within your student portal.

1 You & Your Trip

2 General Health

3 Vaccination Info

4 BVI Information

5 Uploads

6 Review & Remind

Enrollment ID
Submitted Vaccination Info
Medical ID
COVID Risk Mitigation Self Certification Form

This form is to be submitted no earlier than the day before travel to the program.

Since the group’s health and well-being in part relies on each participant arriving in good health, we require that each participant complete and submit the following form the day before their program begins.
You'll need to have the following documents/scans available to complete the form.

Vaccination Card - Scanned Copy

COVID-19 Test Result - Scanned Copy
Student Information
First Name*
Last Name*
Email*
Will you be under the age of 18 at any point during the trip?*
Parent/Guardian Information
First Name*
Last Name*
Email*
Trip Information
Where is your trip scheduled to start?*
Which vessel are you joining?*

Health Questions

Body Temperature
COVID-19 Like Symptoms
Over the past 10 days, have you experienced any symptom that may be associated with COVID-19, such as an elevated body temperature of 100.4 degrees and above, dry cough, loss of taste or smell, etc*
Please give us all of the details of these symptoms (types and dates) and what actions you took.*

Appropriate Personal Health Decision Making
Over the past 10 days, have you, at minimum, adhered to your Government, State or Local Municipalities' requirements and recommendations regarding non-essential travel, social distancing, mask wearing, in keeping with your vaccination status.*

Knowledge of Possible Exposure
Have you been in close physical contact with anyone who has tested positive for COVID-19 within 14 days of your trip's start date?*
Please give us all of the details of this interaction and the steps you have taken to ensure that you are not currently infected.*

COVID-19 Vaccination
We require all students to be fully vaccinated* for COVID-19 before the voyage start date.
Which COVID-19 vaccine did you receive*
Enter the date of your initial vaccination*
Date Format: MM slash DD slash YYYY

mm/dd/yyy
Does the vaccine you received require a single dose, or two doses?*
Enter the date that you received your second dose of vaccine.*
Date Format: MM slash DD slash YYYY

mm/dd/yyy
Fully Vaccinated Requirement*
All students are required to be "Fully Vaccinated" by the start date of the program. An individual is considered “Fully Vaccinated” 14 days after they have received their final dose of vaccine. Please affirm that you have attained this status.

Vaccination Card Upload*
Accepted file types: jpg, gif, png, pdf.
Please upload one single document of a scanned copy of your official COVID-19 vaccination card. This document must be of good quality and include all pages/sides of your card. File type can be jpg, gif, png, pdf and the max size is 5MB

Tell us how you're getting to Tortola in the BVI*
6. St. Thomas Arrival Authorization
Have you received your St. Thomas Travel Authorization Email showing the green QR code and have a copy printed to carry with you?*
See example below
This is a requirement to transit through St Thomas. Do not attempt to travel without this authorization. You must apply for this authorization on the screening portal here - US VIrgin Islands Travel Portal

PLEASE DO NOT CONTACT US REQUESTING HELP WITH YOUR AUTHORIZATION EMAIL AS WE HAVE NO ABILITY TO CONTACT THE USVI AUTHORITIES ON YOUR BEHALF.
6. Transit Authorization

Many countries require you to submit an application in order to transit through their airport on the way to your final destination. You indicated that you are planning to fly to Tortola via a location other than St. Thomas, so we are unable to guide you on the specifics of your situation.
Have you researched and received any necessary documentation to be allowed to transit through the country/countries on your travel itinerary?*
7. 48hr Lab Approved Antigen Test Result
Have you printed a copy of the negative, Lab approved COVID-19 rapid antigen test?*
This is the test that you took within 48hrs of travel. This test must show your full name, the lab name, testing date, and location as well as the test type. You may be required to present these test results multiple times throughout your travel day.

1. Negative COVID-19 RT-PCR Test Upload
Have you taken a COVID-19 RT-PCR test within 72 Hrs of traveling to the vessel, and have proof of a negative result?*
Please note that “72 hrs of traveling to the vessel” is defined as 72 hrs from the time that a student can definitively prove that they started traveling to the vessel, so the date and time of a student’s first flight is the benchmark typically used. Test results must clearly show the following:
- Laboratory name and contact details
- Student’s name
- Test taken, stating either RT-PCR
- Date and time that the sample was taken
- Negative result for Covid-19 or SARS-CoV-2
This is a requirement to join our program and board the vessel. Do not travel to the embarkation point. Please contact us on +1.941-924-6789.
Negative Covid-19 Test Upload*
Accepted file types: jpg, jpeg, gif, png, pdf.
Please scan/photograph and upload a digital copy of your negative test result. The test date must be clearly visible and fall within the specific time frames defined above. You must carry the original with you for verification. (30mb Max file size)

7. Risk Mitigation During Travel
How are you planning to travel to the embarkation point?*
> Click on the link below and watch a short 2:33m video created by CNN's medical correspondent Dr. Sanjay Gupta. During the video, Dr. Gupta demonstrates how to safely navigate the airport and what you should do once you're aboard the plane.
Dr. Gupta's tips for staying safe before - and during - your flight

> Click on the link below and watch a short 1:55m video created by CNN's medical correspondent Dr. Sanjay Gupta. During the video, Dr. Gupta demonstrates how to stay safe on a road trip.
Dr. Gupta demonstrates how to stay safe on a road trip.

8. PPE Supplies
Please make certain that you are bringing the following PPE with you for use while traveling to and from the program:

Three (3) N95 or KN95 disposable masks for travel days (use the absolute best while on the plane)

Three (3) quality washable cloth face masks for everyday use ashore

Two (2) 3.4oz "travel size" bottles of hand sanitizer

Two (2) "travel size" packs of antibacterial wipes to clean common surfaces while traveling

Do you have the above items ready to go?*
Please re-review the Covid Addendum to the Participant Agreement
COVID-19 ADDENDUM TO PARTICIPANT AGREEMENT THIS DOCUMENT CONTAINS A RELEASE OF LIABILITY AND WAIVER OF CERTAIN LEGAL RIGHTS. Please read this COVID-19 Addendum to Participant Agreement (hereafter “Addendum”) carefully before signing. This Addendum must be signed by all participants, and a parent or legal guardian if the participant is a minor. This Addendum is intended to supplement and not replace the Participant Agreement. In consideration for participant being permitted to participate in the services offered by ActionQuest LLC, individually and d/b/a Global Expeditions Group, GoBeyond Student Travel, and Sea|mester, and their owners, officers, directors, members, employees, agents, subcontractors, representatives, and volunteers, including its medical consultants and all other persons or entities affiliated with them (collectively “GXG”), I (participant and/or parent of a minor participant) acknowledge and agree as follows: • COVID-19 is a highly contagious virus that could cause various severe symptoms including, but not limited to, cough, shortness of breath or difficulty breathing, fever, chills, repeated shaking, muscle pain, headache, new loss of taste or smell, persistent chest pain or pressure, confusion, and even death; • COVID-19 could be transmitted by people who may not be experiencing any symptoms of the virus and it is possible that someone may be positive for the virus without knowing it; • GXG has implemented numerous policies and procedures to deal with the COVID-19 pandemic including those that have been and/or will be provided to me and those available on its websites. These include but are not limited to policies, procedures, and travel requirements surrounding vaccinations, “boosters”, testing, social distancing, quarantines, isolations, and mask usage. I understand that these policies and procedures are frequently evolving and being updated to comply with the latest requirements and recommendations of governing authorities and health departments, not only in the United States but in the countries to which I will be traveling. I agree to comply with, and be bound by, all GXG policies and procedures in effect at the time of my Program. I also understand that my failure to comply with any of these policies and procedures could result in my immediate dismissal from the Program at my sole expense. • Due to the nature of COVID-19, possible variants and a GXG Program, among the inherent risks of my participation in the Program is that I may become infected with COVID-19 and/or transmit it to other individuals despite GXG’s compliance with its policies and procedures, and regardless of whether I comply with these policies and procedures; • GXG staff members are, and have been, available if I have further questions about GXG’s COVID-19 policies and procedures or the associated risks of participating in a GXG Program during this pandemic. Parent/s give permission for their minor child to participate in a GXG Program despite these risks and agree to discuss these risks with their child; and • All terms of the Participant Agreement shall apply to COVID-19 and the contents of this Addendum. Therefore, I understand and acknowledge that the Liability Release and Indemnity Agreement contained in the Participant Agreement shall apply in its entirety to any and all claims, liabilities, suits or expenses in any way related to, or arising out of, COVID-19. IF THE PARTICIPANT IS A MINOR AT ANY TIME DURING A PROGRAM, FLORIDA LAW REQUIRES THAT THE FOLLOWING STATEMENT BE PROVIDED IN UPPERCASE TYPE, AT LEAST 5 POINTS LARGER THAN, AND CLEARLY DISTINGUISHABLE FROM, THE REST OF THE TEXT OF THE WAIVER OR RELEASE. SECTION 744.301, FLORIDA STATUTES (2019). NOTICE TO THE MINOR CHILD’S NATURAL GUARDIAN READ THIS FORM COMPLETELY AND CAREFULLY. YOU ARE AGREEING TO LET YOUR MINOR CHILD ENGAGE IN A POTENTIALLY DANGEROUS ACTIVITY. YOU ARE AGREEING THAT, EVEN IF THE RELEASED PARTIES USE REASONABLE CARE IN PROVIDING THESE ACTIVITIES, THERE IS A CHANCE YOUR CHILD MAY BE SERIOUSLY INJURED OR KILLED BY PARTICIPATING IN THESE ACTIVITIES BECAUSE THERE ARE CERTAIN DANGERS INHERENT IN THESE ACTIVITIES WHICH CANNOT BE AVOIDED OR ELIMINATED. BY SIGNING THIS FORM YOU ARE GIVING UP YOUR CHILD’S RIGHT AND YOUR RIGHT TO RECOVER FROM THE RELEASED PARTIES IN A LAWSUIT FOR ANY PERSONAL INJURY, INCLUDING DEATH, TO YOUR CHILD OR ANY PROPERTY DAMAGE THAT RESULTS FROM THE RISKS THAT ARE A NATURAL PART OF THESE ACTIVITIES. YOU HAVE THE RIGHT TO REFUSE TO SIGN THIS FORM, AND THE RELEASED PARTIES HAVE THE RIGHT TO REFUSE TO LET YOUR CHILD PARTICIPATE IF YOU DO NOT SIGN THIS FORM. PARTICIPANT AND/OR PARENT OF A MINOR PARTICIPANT AGREE: I HAVE CAREFULLY READ, UNDERSTAND, AND VOLUNTARILY SIGN THIS DOCUMENT AND ACKNOWLEDGE THAT IT SHALL BE EFFECTIVE AND LEGALLY BINDING UPON ME, MY SPOUSE, PARTICIPATING CHILD AND OTHER CHILDREN, AND PARTICIPANT’S/PARENT’S OTHER FAMILY MEMBERS, HEIRS, EXECUTORS, REPRESENTATIVES, SUBROGEES, ASSIGNS, AND ESTATE. ALL PARTICIPANTS MUST SIGN BELOW. IF PARTICIPANT IS A MINOR (THOSE UNDER 18 YEARS OF AGE), ONE OF THE PARTICIPANT’S PARENTS OR LEGAL GUARDIANS MUST ALSO SIGN BELOW. I ACKNOWLEDGE THAT THIS AGREEMENT IS INTENDED TO BE INTERPRETED AND ENFORCED TO THE FULLEST EXTENT ALLOWED BY LAW. I understand that my signature is valid and legally binding whether I choose to electronically sign or sign a printable version of this Document.

Declaration

My signature below indicates that I have answered all of the questions completely and truthfully in the knowledge that minimizing the possibility of importing an active infection into the program is a primary risk management strategy.
Student Signature*
Parent Signature*

Email
This field is for validation purposes and should be left unchanged.

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Pre-Trip COVID-19 Self-Certification Form

Pre-Trip COVID-19 Self-Certification Form

Please note: This is a non-submittable sample form.

Please complete this form using the specific link within your student portal.

COVID Risk Mitigation Self Certification Form

Student Information

Parent/Guardian Information

Trip Information

Health Questions

Body Temperature

COVID-19 Like Symptoms

Appropriate Personal Health Decision Making

Knowledge of Possible Exposure

COVID-19 Vaccination

6. St. Thomas Arrival Authorization

6. Transit Authorization

7. 48hr Lab Approved Antigen Test Result

1. Negative COVID-19 RT-PCR Test Upload

7. Risk Mitigation During Travel

8. PPE Supplies

Declaration

Title