Llangollen Railway Safety Management System
Document Number: LR-SMS-6.3.1.9b
STRICTLY CONFIDENTIAL
Llangollen Railway Trust Ltd.
Ymddiriedolaeth Rheilffordd Llangollen Cyf., Yr Orsaf, Ffordd yr Abaty, Llangollen LL20 8SN
Llangollen Railway Trust Ltd., The Station, Abbey Road, Llangollen LL20 8SN
01978 860979 or
info@llangollen-railway.co.uk
www.llangollen-railway.co.uk
Health Declaration for Footplate/Cab Ridesand Railway Experience Courses
When making this health declaration, please remember that you
must
be able to:
climb up to the cab from track-level,
stand for long periods (up to 45 minutes),
walk along railway tracks, possibly for some distance,
move out of danger, quickly if necessary.
Please note also that:
you may encounter heat, noise, vibration, possible sudden violent movement or uneven floors, and
you will pass through a long single-bore tunnel with no ventilation shafts.
HAVING READ AND NOTED THE ABOVE, PLEASE ANSWER THE FOLLOWING QUESTIONS HONESTLY:
1. Do you consider yourself to be at least moderately fit?
YES
NO
2. Do you have sufficient mobility to move around easily?
YES
NO
3. Do you have adequate resilience to the harsh environment?
YES
NO
4. Have you any significant defect of vision not corrected by wearing glasses?
YES
NO
5. Do you suffer from fits, faints, blackouts, vertigo or dizziness?
YES
NO
6. Do you have any conditions which might bring about a sudden loss of consciousness?
YES
NO
7. Do you have any significant impairment of hearing not corrected by wearing hearing aids?
YES
NO
8. Do you suffer from any other physical or mental condition which might affectyour footplate experience with us? If yes, please contact the Admin Office to check eligibility
YES
NO
DECLARATION BY THE PARTCIPANT
I declare that the answers given above are truthful to the best of my knowledge and belief. I agree to provide
further information if requested. I understand Llangollen Railway Trust Ltd reserves the right to seek further
clarification on the responses to any of the above questions.
Name
First Name
Last Name
Signed
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Contact Address
Tel No
Format: (000) 000-0000.
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