Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

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Date of Arrival *

MM

DD

YYYY

Certification *

VT Traveler Guidelines https://accd.vermont.gov/content/stay-home-stay-safe-sector-specific-guidance#lodging-accommodations

I certify that I have reviewed the State of Vermont out-of-state traveler guidelines and travel map and comply with current health and safety requirements for traveling to, from, and within the State of Vermont. I further certify that I understand all travelers should stay home if ill (with any symptoms); maintain physical distance of at least 6’ from anyone outside their household; wear a cloth mask when in public spaces; and wash or sanitize hands often.

*

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.