COMPENSATION FOR MINOR'S INJURIES
We, _______________________________ and _____________________________ (Names), of __________________________________________________________ ___________________________________________________ (Address), the parents of ________________________ (Name of minor), a minor, born _____________ (Date), received from __________________________________ (Name), (if applicable, add: a corporation organized and existing under the laws of the State of ____________,) (or, if a corporation: with its principal place of business located at) _____________________________________________________________________ (Address), the amount of ____________ dollars ($___________) in full satisfaction of all claims for the following injuries and damages: __________________________ __________________________________________________________________
The above-described injuries and damages were suffered by ______________________
(Name of minor) on __________ (Date), as a result of _________________________ ______________________________________________________________ (Specify).
We, _______________________________ and __________________________ (Name), further, jointly and severally, as parents and legal guardians of _____________ (Name of minor), release and discharge ______________________________________ (Name), (if applicable, insert here: and _________________________ (His or her) heirs, legal representatives and insurers or, if a corporation, its successors, assigns and insurers) of and from all liability, claims or demands arising from the above-described injuries to _______________________________________________________ (Name of minor).
We, _____________________________ and _____________________________, shall indemnify _________________________, (and ________________ (his or her) heirs,
legal representatives and insurers or, if a corporation, its successors, assigns and insurers) against loss or expense with respect to any action, claim or demand by any person for damages based on the above-described injuries to _____________________ (name of minor).
In witness whereof, we, ____________________ and ______________________, have executed this release at ___________________________________________________ (Designate place of execution) on ______________ (Date).
Approved as to Form and Content By:
Judge of _________________________________ (Court)