Release executed on __________ (Date), by
__________________________________ (Name), here referred to as Releasor of
_______________________________________ (Address), individually and as parent
and guardian of ___________________ (Minor), to
________________________________ (Name), of _____________________________
here referred to as Releasee.
__________ (Date), at _____________________________________ (Location),
an accident occurred, resulting in bodily injuries
to _____________________________ (Name), a minor, born on _____________________
(Date), here referred to as the minor.
is the guardian of the minor ___________________________ (Pursuant to
________________ (Cite appropriate statute) or as the result of an order
entered by the ______________________ (Specify court) on __________ (Date), in
the action entitled _______________________________ v
______________________________, Civil No. ____________________, (or otherwise
as the case may be).
are made against _________________________________________ (Name) (Releasee) as
compensation for such injuries by ________________________________ (Releasor)
individually and as guardian of the minor.
D. A dispute
has arisen with respect to the legal liability for such injuries, such
liability being expressly denied by Releasee.
In consideration of the sum of __________________
Dollars ($___________ ) from Releasee, receipt of which is hereby acknowledged
both individually and as the lawful guardian of the above-named minor, Releasor
voluntarily and knowingly executes this release with the intent of effecting
the extinguishment of obligations as herein designated.
Releasor, with the intention of binding
_______________________ (Himself or herself)
and ____________________________ (Minor),
___________ (His or her) respective
heirs, legal representatives and assigns, expressly
releases and discharges Releasee and ___________ (His or her) heirs and legal
representatives from all claims, demands and causes of action that Releasor
ever had, now has, or may have arising from such accident
and injuries, and by reason of any and all known and
unknown, foreseen and unforeseen bodily and personal injuries, damage to
property, and the consequences thereof that have been or may after be sustained
by the minor and by any other person or persons having a legal interest therein
in consequence of such accident and injuries.
Releasor, as the guardian of
_________________________________ (Minor), hereby expressly stipulates and
agrees, in consideration of the above payment, to indemnify
and hold harmless _____________________________
(Releasee), and Releasee’s heirs, successors, assigns, executors and
administrators against loss from any further claims, demands or actions that
may subsequently be brought by the minor or by any other
person or persons on account of damages of any
character resulting in any way from
the above-described accident to minor. Releasor
further agrees to reimburse and make
good to Releasee any loss, damages or costs Releasee
may have to pay as a result of any
such action, claim or demand.
(Add, if necessary:
Releasor and Releasee agree that this release will not become effective unless
and until it is approved by the court.)
In witness whereof, Releasor has executed this
release at _________________________ (Designate place of execution) the day and
year first above written.
Approved as to Form and Content By:
Signature of Judge Date
__________________________________________________ (specify court)