Vermont COVID-19 Compliance Form for Attendance at MMSCA Functions
Before beginning participation in MMSCA programming or events and entering MMSCA property this form must be completed by the participant.

If the participant is younger than 18 years of age, this form must be completed by their parent or guardian.

If you should answer ‘False’ to any question, you many not attend MMSCA.
Email *
Full Name *
Of the individual completing this form.
Club/Academy/Organization *
List any idividuals under the age of 18 under your care.
1) Travel: I certify
a. I/we have not left the state of Vermont for any reason except daily essential travel in the past 14 days; OR

b. I/we have traveled to Vermont from another state, and I have completed a 14-day self-quarantine**;

**a 14 day quarantine may be ended early with a negative PCR SARS-CoV-2 (COVID-19) test result from a sample taken on day 7 of quarantine, the first day of quarantine being day zero (0).

NOTE: Travel and returning to Vermont by a fully vaccinated individual does not require quarantine, after 14 days has passed since receiving the final dose.
My actions are consistent with the above statement. *
2) I certify that:
a. I/we have had no close contact with a person suspected to have COVID-19 within the last 14-days*; AND

b. I/we have had no close contact with a person traveling or returning to Vermont from another state prior to their completion of quarantine.

c. I/we have not had any gatherings* with more than 2 households at a time, indoors or outdoors aside from organized outdoor recreation, i.e. MMSCA programming.

*a 14 day quarantine may be ended early with a negative PCR SARS-CoV-2 (COVID-19) test result from a sample taken on day 7 of quarantine, the first day of quarantine being day zero (0).
**gatherings between fully vaccinated individuals and/or fully vaccinated households is permitted.
My actions are consistent with the above statement. *
3) I certify that:
I/we do not currently, and have not had in the past 24 hours, any of the following symptoms consistent with COVID-19: A fever above 100.4° F / 38° C, Cough, Chills, Muscle or joint pain, Sore throat, Headache, New loss of taste or smell.
My experience is consistent with the above statement. *
4) I certify that:
I/we meet the criteria described in 1-3 above. Please provide an accurate list of the names of all persons under 18 or otherwise in your care above
My actions are consistent with the above statement.
Clear selection
5) I certify that:
I have read and understand this entire Certificate of Compliance and make the above certifications under pains and penalties of perjury.
My actions are consistent with the above statement. *
Local Physical Address *
Street, City/Town, State, Zip
Mailing Address (Reenter if the same as Local Physical Address) *
Street, City/Town, State, Zip
Signature *
Initial Below
Today's date *
MM
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DD
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YYYY
A copy of your responses will be emailed to the address you provided.
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