Have you or your children travelled internationally and returned to the UK, in the last 14 days? Yes No

Have you or your children knowingly been in contact with any person who has returned from overseas in the last 14 days? Yes No

Have you or your child/ren been exposed to a confirmed case of Coronavirus? Yes No

Have you or your child/ren had contact with person(s) with flu-like symptoms? Yes No

Do you have any of the following symptoms? (Please tick all that apply)

Child/rens name/s

Parents' name

Contact Number

Address

Your Name