SPECIAL REQUIREMENTS DISCLAIMER
Medway Homestays want to make our guest stay as pleasant and safe as possible. To ensure this happens we need
to be as fully informed about any conditions or needs that will affect the stay with a host family. We do not need to
know on this form about likes and dislikes this is purely for things that effect health & safety. It is important that
we have as much information as possible.
Although we always try to be as inclusive as possible, there may be occasions where we are unable to find a suitable
host family accommodation.
Personal Details
Details of person with allergy/ medical conditions
First Name: _______________________________________
Surname: ________________________________________
Food Allergies
We cannot guarantee that products in host family’s homes are free from allergens (this includes washing products).
Host family accommodation is in people’s homes where it is highly likely they will be preparing and cooking with
allergens. We recognise the seriousness of food/ product allergies and therefore require as much information as
possible about the allergy (the seriousness, the reaction, and medication). We require information about what can
and can’t be eaten, and whether the allergy is just for the actual food or products containing the allergen.
Examples:
1. Allergy to eggs, cannot eat eggs in their whole form such as a boiled or fried egg but can eat products with
egg in such as cakes.
2. Allergy to nuts, cannot eat whole nuts or any food with traces of nuts.
Medway Homestay cannot be held responsible should anyone staying with a host family have any side effects or
be taken ill during their stay or once they return home due to any food substances supplied or any cross
contamination of food products. If you have an allergy you stay with a host family at your own risk.
Information passed to us regarding food allergies from agents, schools, parents/guardians of a child/teacher will be
passed to our Host Families who will endeavour to prepare and supply food products as per this information.
Has an allergy to (please state celiac not gluten intolerant if appliable):
1. ___________________________________
2. ___________________________________
3. ___________________________________
The allergy is MILD/ MODERATE/ SEVERE (please delete as appropriate, if severe please answer severe allergy
questions below)
1
MHS is a trading name of Medway Homestays Limited
5 Oxford Road, Gillingham Kent, ME7 4BP
Contact: Lisa Sullivan: +44 07971 719114 / Lisa Young: +44 7766 720313
SPECIAL REQUIREMENTS DISCLAIMER
Please tell us more details about the allergy (whole foods/ traces, what they can and can’t eat), and the reaction:
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
For all severe allergies and Celiac disease please answer the below questions:
1. Has the allergy been diagnosed by a doctor?
Yes / No
2. Does the reaction only occur from food being ingested or also from smell/ touch?
Ingested only/ Ingestion & touch/ Smell, touch & ingestion.
3. Can food be cooked in the same oven at the same time as the allergen? If no you will need to bring your own
food/ microwave meals.
Yes/ No
4. Can the allergen be in the house? (Or do you require the host family’s home to be allergen free).
Can be in the house/ Home needs to be allergen free.
5. Any other advice you think will be useful to the host family?
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Has an EpiPen:
Yes/ No
Other medication in-case of any of any reactions (please note families cannot administer any medication)
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
Medical Requirements
2
MHS is a trading name of Medway Homestays Limited
5 Oxford Road, Gillingham Kent, ME7 4BP
Contact: Lisa Sullivan: +44 07971 719114 / Lisa Young: +44 7766 720313
SPECIAL REQUIREMENTS DISCLAIMER
If your child has any medical requirement including spectrum disorders (such as ADHD, ADD, Autism, mental health
issues, bed wetting etc) that will require additional attention by our host families. Medway Homestay will try our
best to accommodate these requirements, but it will not always be possible. Please provide the following
information:
Additional need/ medical condition:
_______________________________________________________________________________________________
_______________________________________________________________________________________________
How does this affect them:
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
What additional attention do they need or anything the family should look out for?
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
Medication (please note families cannot administer any medication):
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
Signature
Please sign below to state all details in this form are correct, if under 18 to signed by parent or guardian.
Name:
Signature:
Date:
3
MHS is a trading name of Medway Homestays Limited
5 Oxford Road, Gillingham Kent, ME7 4BP
Contact: Lisa Sullivan: +44 07971 719114 / Lisa Young: +44 7766 720313
