Fill and Sign the Complaint Regarding Injury to Child at Day Care Form

IN THE ______________ COURT OF ______________ COUNTY STATE OF ________________       ) )       ) Petitioner/Plaintiff, ) ) ) NO.       Vs. ) )       ) Respondent/Defendant ) ) COMPLAINT COMES NOW, the plaintiffs in the above-styled cause and as for their complaint, state as follows: 1. Plaintiff ___________________ is over the age of nineteen (19) years, a resident of __________ County and the mother of plaintiff, ____________. 2. Plaintiff, ____________ is a minor and is suing by and through her mother, and next friend, ___________________. 3. Plaintiff ____________ is over the age of nineteen (19) years, is a resident of __________ County, and is bringing a claim for medical bills he incurred as a result of medical care rendered to plaintiff, ____________. 4. _____________________________, d/b/a ____________ Day Care (hereinafter referred to as “___________s”) is an __________ corporation, qualified to do business in __________ and is doing business in __________ County, __________. 5. Defendants, A, B, C, D, E and F, being those persons or entities who negligently hired, trained, supervised, retained, and/or disciplined the agents, servants and/or employees - 1 - charged with or otherwise rendering daycare services to ____________; negligently or wantonly operated, staffed, maintained, or controlled the daycare facility which rendered daycare services to the plaintiff _________ the persons or entities who contracted with plaintiffs to render daycare services to the plaintiff ____________ whose true names and legal identities are otherwise unknown to the plaintiffs at this time but who will be added by amendment when ascertained, individually and jointly. 6. Plaintiffs and Defendants entered into a contract in which the defendants, and each of them, agreed to render daycare services for the plaintiff minor, ____________. 7. On or about the ______ day of____________, 20____, while in the care, control, and custody of ___________, plaintiff ____________ sustained personal injuries. 8. Defendants, and each of them, at all times material to this complaint, were acting as agents, servants and/or employees of one another, or were otherwise engaged in a joint venture. Defendants, and each of them, at all times material to this complaint, were acting through their agents, servants and/or employees. COUNT ONE (Negligence) 9. Plaintiffs adopt and incorporate by reference paragraphs 1 through 8 as if fully set out herein. 10. The defendants, and each of them, negligently hired, trained, supervised, retained and/or disciplined, those agents, servants and/or employees charged with rendering daycare services to _____________or otherwise who assumed a duty of rendering daycare services to ____________. Said defendants, and each of them, negligently operated, controlled, staffed, and/or maintained, the daycare facility charged with rendering daycare services to ____________. - 2 - 11. As a proximate cause of said negligence on the part of the defendants, and each of them, which combined and concurred, the plaintiff ____________ sustained personal injuries, experienced pain and suffering, mental anguish and sustained a scar. Plaintiff ____________ incurred medical bills for the medical treatment rendered ____________ and may incur future medical bills in connection with ______________ injuries. WHEREFORE, plaintiffs demand judgment against the defendants, and each of them, for compensatory damages in excess of the minimal jurisdictional amounts of this Court. COUNT TWO (Wantonness) 12. Plaintiffs adopt and incorporate by reference paragraphs 1 through 8 as if fully set out herein. 13. The defendants, and each of them, wantonly hired, trained, supervised, retained and/or disciplined, those agents, servants and/or employees charged with rendering daycare services to ____________ or otherwise who assumed a duty of rendering daycare services to ____________. Said defendants, and each of them, wantonly operated, controlled, staffed, and/or maintained, the daycare facility charged with rendering daycare services to ____________. 14. As a proximate cause of said wantonness on the part of the defendants, and each of them, which combined and concurred, the plaintiff ____________ sustained personal injuries, experienced pain and suffering, mental anguish and sustained a scar. Plaintiff ____________ incurred medical bills for the medical treatment rendered ____________ and may incur future medical bills in connection with _______________injuries in the future. WHEREFORE, plaintiffs demand judgment against the defendants, and each of them, for compensatory and punitive damages in excess of the minimal jurisdictional amounts of this Court. - 3 - COUNT THREE (Breach of Contract) 15. Plaintiffs adopt and incorporate by reference paragraphs 1 through 8 as if fully set out herein. 16. Although the plaintiffs have complied with all the provisions of the contract between the plaintiffs and defendants, both expressed and implied, written and oral, on their part, or have stood ready, willing and able to comply with such agreements, the defendants, and each of them have breached said contract. 17. As a proximate result of said contractual breaches on the part of the defendants, and each of them, which combined and concurred, the plaintiff ____________ sustained personal injuries, experienced pain and suffering, mental anguish and sustained a scar. Plaintiff ____________ incurred medical bills for the medical treatment rendered ____________ and may incur future medical bills in connection with _______________injuries in the future. WHEREFORE, plaintiffs demand judgment against the defendants, and each of them, for compensatory damages, consequential damages, incidental damages, and mental anguish for a sum in excess of the minimal jurisdictional amounts of this Court plus interest and costs. _______________________________________ PLAINTIFFS RESPECTFULLY DEMAND A TRIAL BY JURY Respectfully submitted, Dated: Name: Title: Address: Address: City, State, Zip: Phone: Fax: E-Mail: - 4 - Attorney No.: CERTIFICATE OF SERVICE I, ______________________________, do hereby certify that I have this day mailed, U.S. Mail, postage prepaid, a true and correct copy of the above and foregoing to __________________________________, at the following address; ___________________________________________________________________ THIS the ____ day of _____________, 20____. _________________________________ PLAINTIFFS RESPECTFULLY REQUEST ________________________ INC., d/b/a __________’S DAYCARE BE SERVED BY CERTIFIED MAIL AS FOLLOWS: ______________________________ _________________________ ______________________________ - 5 -