FirstName

Last Name

Email

Have you had any symptoms of COVID-19 in the past 2 weeks?

YesNo

Have you traveled anywhere in or outside of England in the past month?

YesNo

Have you been in contact with people infected, suspected or diagnosed with COVID-19?

YesNo

Have you received the COVID-19 vaccination? Select all that apply

Are you or anyone in your home at high risk of COVID-19?

YesNo

Are you or anyone in your home shielding for COVID-19?

YesNo

I certify that the information that I provided is correct and I authorise Perfect Host Homestay Ltd to use it. I understand the information given will determine whether I can host a student or not.

I can confirm I will notify Perfect Host Homestay Ltd if any of the circumstances according to this form change a week before the student is due to arrive.