PARENTS' RELEASE
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: __________________________
__________________________________________________________________
____________________________ (Recount).
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).
_____________________________________ _____________________
Signature Date
_____________________________________ _____________________
Signature Date
Approved as to Form and Content By:
_____________________________________ _____________________
Signature Date
Judge of _________________________________ (Court)
