Incident Report & Decline of Further Medical Attention

Incident Details

Date of Incident: ____________________________
Time of Incident: ____________________________
Location of Incident: ____________________________
Detailed Description of Incident:

Incident Photos Attachment:

*Attach any relevant photos of the incident.

Injury Assessment:

Type of Injury: ____________________________
Severity (Minor/Moderate/Serious): ____________________________
First Aid Administered: ____________________________
Treatment Details & Notes:

Recommended Medical Attention:

Given the nature of the injury, we recommend the following medical attention:

Decline of Further 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.

Participant Details

Full Name: ____________________________
Date of Birth: ____________________________
Signature: ____________________________ Date: __________
Contact Phone: ____________________________
Email: ____________________________

Facility Witness Details

Full Name: ____________________________
Role/Position: ____________________________
Signature: ____________________________ Date: __________

*Note: This form is a basic template. Ensure you consult with a legal professional in your jurisdiction to confirm its comprehensiveness and adherence to local laws.