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Back to Forms for 'Parent and Child'.



(TYPE 1)



Release executed on __________ (Date), by __________________________________ (Name), here referred to as Releasor of _______________________________________ (Address), individually and as parent and guardian of ___________________ (Minor), to ________________________________ (Name), of _____________________________

________________________________________ (Address), here referred to as Releasee.





A.  On __________ (Date), at _____________________________________ (Location),

an accident occurred, resulting in bodily injuries to _____________________________ (Name), a minor, born on _____________________ (Date), here referred to as the minor.


B.  Releasor 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).


C.  Claims 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.



_____________________________________                     _____________________

Signature                                                                                                           Date



Approved as to Form and Content By:



_____________________________________                     _____________________

Signature of Judge                                                                                          Date


Judge of __________________________________________________ (specify court)


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