RIGHT OF REFUSAL OF MEDICAL AID
Show Name: _________________________________________________
I hereby refuse the first aid treatment recommended to me by the First Aid Person employed by my
production for the illness or injury incurred by me on this date.
In signing this waiver, I release the First Aid Person, the Production and its personnel from any
liability resulting from this refusal to accept such first aid treatment.
Injured’s or Guardian’s Signature
Injured’s Name (print)
Injured’s Cell #
Job Title or Position
Guardian’s Name in case of minor
Relationship to Injured
First Aid Person Signature
First Aid Person Name (print)
Witness Name (print)
Witness Cell #
This form should be signed, dated and returned to the Production Safety Representative.
(Form 16) Right of Refusal of Medical Aid