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1. Please enter your Full Name including any middle names: *
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2. Please indicate your gender: *
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3. Please enter your Date of Birth: *
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4. Please describe your ethnicity: *
5. Please state below the date and type of any Covid-19 vaccines you have received to date.
(Please leave blank if you have not yet received your first dose of a Covid-19 vaccine)
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9. Please enter the address you will be self-isolating at if different from the above address:
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10. Please enter the date of your arrival to the UK:
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11. Please state the time of your arrival in the UK?
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12. Which country or territory were you travelling from when you arrived back to the UK? *
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13. Please state below any countries that you transited through while travelling back to the UK? (Please write NONE if not applicable) *
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14. Please state the date on which you departed from (or last transited through) a country outside of the UK? *
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15. Please state your coach number, flight number or vessel name (as appropriate): *
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23. As part of the "Test and Release" scheme we are legally obliged, on request, to share data submitted on this form with Public Health England or, if approached, with the Police (in exceptional circumstances where they need to confirm a quarantine period). Please tick the box below to indicate you understand this and consent: