Date of Incident: ____________________________Time of Incident: ____________________________Location of Incident: ____________________________Detailed Description of Incident:
*Attach any relevant photos of the incident.
Type of Injury: ____________________________Severity (Minor/Moderate/Serious): ____________________________First Aid Administered: ____________________________Treatment Details & Notes:
Given the nature of the injury, we recommend the following medical attention:
I, ____________________________ (full name), after sustaining an injury at the paintball facility, acknowledge that I have been informed of the nature of my injury and the potential risks of not seeking further medical attention.
I hereby voluntarily decline any recommendations for further medical care, including ambulance or emergency services. By signing this form, I release the paintball facility, its officers, agents, and employees from any claims, liabilities, or demands that may arise from my decision to decline further medical treatment.
I understand that this form does not prevent me from seeking medical attention at a later time. However, I waive any claims against the paintball facility related to the injury sustained on the date mentioned above and my decision to decline further medical care.
Full Name: ____________________________Date of Birth: ____________________________Signature: ____________________________ Date: __________Contact Phone: ____________________________Email: ____________________________
Full Name: ____________________________Role/Position: ____________________________Signature: ____________________________ Date: __________
You are all set.
