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.

Enrollment ID
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.
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
For which trip are you enrolled?*
Connecticut Requirements
Your trip starts in Mystic Connecticut and, pursuant to Governor Lamont's Executive Order No. 7III, anyone traveling into Connecticut from a state that has a new daily positive test rate higher than 10 per 100,000 residents or a state with a 10% or higher positivity rate over a 7-day rolling average are directed to quarantine for a 14-day period from the time of last contact within the identified state. Since we will be quarantining aboard the vessel, we consider this requirement to be met. In addition, anyone entering from one of the identified states must fill out a travel health form upon arrival. Please take the following steps:
- Review the CT guidelines to determine your status. https://portal.ct.gov/Coronavirus/Travel
- If required, you must complete the following online health form before travel. https://appengine.egov.com/apps/ct/DPH/Connecticut-Travel-Health-Form.
When completing this form you will be required to enter an address of the location where you will be quarantining. Please use the following:
STV Argo - 75 Greenmanville Ave
Mystic, CT 06355
I have reviewed the Connecticut Requirements and...*
Maldives Requirements
Your trip starts at the island of Malé and the Maldives and both the Department of Immigration and Department of Health have specific requirements for all arriving individuals..
1. Health Declaration Form for Passengers and Crew
(Note: this step has already been completed) Seven days before travel we need to forward a completed copy of the Health Declaration Form for Passengers and Crew to our agent in the Maldives. You can complete this form at any time during the precautionary period and email it to us at info@seamester.com.
- View a sample, completed form HERE
- Download a blank form HERE
When completing the form you will need the following information:
- “Length of stay” - 30 days
- “Cabin Number” - N/A
- "Purpose of Stay” - Transit
2. Immigration Declaration of Health Form

Complete the following online Declaration of Health via the following link - https://imuga.immigration.gov.mv/ethd/create

THIS FORM CAN BE SUBMITTED NO MORE THAN 24 hours prior to your departure to the Maldives

When completing the form you will need the following information:
- NEW - You will be required to upload a copy of your negative COVID-19 PCR Test before submission
- “Which island will you be residing in” - Hulhumale
- "Address in Maldives” S/Y Vela - Official number #750093
- “Purpose of Visit” - we are unsure of the best answer to this question at this time - will revert back with specific information once we have an answer to this.
3. Print and Carry your Immigration Documentation
We have already emailed each student a personalized pdf document that contains information about their arrival in addition to some of Vela's documentation. This is the document that you will present to the immigration official on arrival. FOR THIS REASON, YOU MUST PRINT THE EMAILED DOCUMENT (PREFERABLY IN COLOR) AND TRAVEL WITH IT TO THE VESSEL. Failure to do so will be problematic. Click this link to view a SAMPLE of the documentation. You should also print and carry the following with you:
- A copy of your Health Declaration Form for Passengers and Crew
- A copy of, or receipt of submission of your online Traveller Health Declaration Form, submitted within 24 hrs prior to your departure to the Maldives
- A printed copy of your Negative Covid-19 PCR test that was taken within 72hrs of your start of travel to the Maldives.
1. Body Temperature
Over the past 14 days, have you taken and recorded your temperature daily?*
Monitoring your body temperature daily throughout the Pre-Trip Precautionary Health Period is a requirement of your participation. You will not be allowed to board our vessel if you have not fulfilled this requirement.
Over the past 14 days, have you experienced an elevated temperature or fever to 100.4 degrees or more?*
Please give us all of the details of your elevated temperature (dates and temps) and what actions you took.*
2. Covid Like Symptoms
Over the past 14 days, have you experienced any symptom that may be associated with Covid-19, such as a 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.*
3. Social Distancing & Appropriate Personal Health Decision Making
Over the past 14 days, have you, at minimum, adhered to your Government, State or Local Municipalities' requirements and recommendations regarding non-essential travel, social distancing, mask wearing, and group sizes etc.*
Over the past 14 days, have you adhered to good standards of personal hygiene during times interacting with others (wearing a mask, hand washing etc.)*
Please give us all of the details of those additional risks you took and why.*
4. Knowledge of Possible Exposure
Have you been in close physical contact with anyone who has tested positive for Covid-19 within 28 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.*
5. Negative Covid-19 PCR Test Upload
Have you taken a Covid-19 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 PCR or 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 PCR 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 7 days of ARRIVAL on the program. You must carry the original with you for verification. (30mb Max file size)
6. Other Covid-19 Test Log
Have you taken any other previous tests for Covid-19*
Please give us all of the details of the tests, including dates, type and results.
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 Reminder
As a reminder, please make certain that you are bringing the following PPE with you for use while traveling to and from the program:
- Three (3) washable cloth face masks
- Three (3) 12.oz bottles of hand sanitizer with an alcohol % of at least 60%.
- One or Two (1/2) 3.4oz bottle(s) of hand sanitizer with an alcohol % of at least 60% (for the plane)
- One (1) pack of 10-20 disposable surgical style face masks. (do not need to be N95)
- One (1) Small pack of 10-20 pairs of disposable nitrile gloves.
- One (1) canister of antibacterial wipes. (we also recommend a smaller flat pack of wipes to carry on the plane, or carefully pack a reasonable number in a ziplock bag for use while traveling if you plan on including the canister in with your checked luggage)
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, members, managers, officers, directors, employees, agents, representatives and volunteers (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 provided to me and those available on its websites. These include but are not limited to policies and procedures surrounding testing, social distancing, quarantines, and personal protective equipment such as masks. Consistent with these policies, I agree, upon completion of the Program, and once I arrive home, to have no contact with anyone I understand to be medically vulnerable under United States Centers for Disease Control and Prevention Guidelines until I have received a negative test for COVID-19 or quarantined for a minimum of 14 days. • 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 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 and a GXG Program, among the inherent risks of my participation in the Program is that I may become afflicted 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*
Phone
This field is for validation purposes and should be left unchanged.

Sailing & Scuba Summer Adventure Camp For Teens

Study Abroad & Gap Year Programs

Global Service & Travel Adventures

The Ultimate STEM & STEAM Experience

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.

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.

Student Information

Parent/Guardian Information

Trip Information

Connecticut Requirements

STV Argo - 75 Greenmanville Ave
Mystic, CT 06355

Maldives Requirements

1. Health Declaration Form for Passengers and Crew

2. Immigration Declaration of Health Form

3. Print and Carry your Immigration Documentation

1. Body Temperature

2. Covid Like Symptoms

3. Social Distancing & Appropriate Personal Health Decision Making

4. Knowledge of Possible Exposure

5. Negative Covid-19 PCR Test Upload

6. Other Covid-19 Test Log

7. Risk Mitigation During Travel

8. PPE Supplies Reminder

Declaration

Sailing & Scuba Summer Adventure Camp For Teens

Study Abroad & Gap Year Programs

Global Service & Travel Adventures

The Ultimate STEM & STEAM Experience

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.

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.

Student Information

Parent/Guardian Information

Trip Information

Connecticut Requirements

STV Argo - 75 Greenmanville Ave Mystic, CT 06355

Maldives Requirements

1. Health Declaration Form for Passengers and Crew

2. Immigration Declaration of Health Form

3. Print and Carry your Immigration Documentation

1. Body Temperature

2. Covid Like Symptoms

3. Social Distancing & Appropriate Personal Health Decision Making

4. Knowledge of Possible Exposure

5. Negative Covid-19 PCR Test Upload

6. Other Covid-19 Test Log

7. Risk Mitigation During Travel

8. PPE Supplies Reminder

Declaration

STV Argo - 75 Greenmanville Ave
Mystic, CT 06355