General Injury Release Form

GENERAL INJURY RELEASE FORM

This General Injury Release ("Release") is entered into as of by and between Releasor Name: of Releasor Address: ("Releasor"), and Releasee Name: of Releasee Address: ("Releasee").

RECITALS

WHEREAS, on or about (the "Incident Date"), Releasor sustained personal injury and/or property damage arising out of an event described as: ;

WHEREAS, Releasor asserts claims or potential claims against Releasee in connection with the Incident; and

WHEREAS, the parties desire to settle and resolve fully and finally all claims, demands, actions and causes of action that Releasor has or may have against Releasee arising out of or related to the Incident, without admission of liability by Releasee.

NOW, THEREFORE

In consideration of the mutual covenants and other valuable consideration set forth in this Release, the receipt and sufficiency of which are acknowledged, the parties agree as follows:

1. DEFINITIONS

For purposes of this Release: (a) "Claim" means any and all claims, causes of action, demands, liabilities, obligations, damages, losses, costs and expenses (including attorneys' fees and costs) of every kind and nature, whether known or unknown, suspected or unsuspected, foreseen or unforeseen, arising out of or relating to the Incident; and (b) "Released Parties" means Releasee and each of Releasee's past and present officers, directors, employees, agents, insurers, successors, assigns and related entities.

2. RELEASE AND WAIVER

Releasor, on behalf of Releasor and Releasor's heirs, executors, administrators, agents, insurers, representatives and assigns, hereby irrevocably and unconditionally releases, acquits and forever discharges the Released Parties from any and all Claims arising out of or relating to the Incident, whether arising in contract, tort (including negligence), strict liability or otherwise, and whether known or unknown, that Releasor may have as of the Effective Date or in the future, except as expressly provided in this Release. This Release extends to Claims of every nature and description.

3. ASSUMPTION OF RISK AND ACKNOWLEDGMENTS

Releasor understands and acknowledges that Releasor may have sustained injuries that are not immediately apparent and that Releasor has had the opportunity to obtain medical examination and advice. Releasor expressly assumes the risk of any such latent or unreported injury. Releasor represents that Releasor is competent and is signing this Release voluntarily and with full knowledge of its legal consequences.

4. CONSIDERATION

Releasor acknowledges receipt of the consideration described above as full and adequate consideration for the release of the Claims described herein. The obligation of Releasee to deliver the consideration is a material inducement for this Release.

5. REPRESENTATIONS AND WARRANTIES

Releasor represents and warrants that Releasor has the full right, power and authority to enter into this Release, that no other person or entity has any interest in the Claims released hereby, and that Releasor has not assigned or transferred any such Claims to any person or entity. Releasor further represents that Releasor has not filed and will not file any suit or claim against any Released Party relating to the Incident.

6. INDEMNIFICATION

To the fullest extent permitted by law, Releasor agrees to indemnify, defend and hold harmless the Released Parties from and against any claims, demands, losses, liabilities, costs and expenses (including attorneys' fees) asserted by any third party arising out of or related to any breach of Releasor's representations or any claim released by this Release.

7. NO ADMISSION OF LIABILITY

The parties agree that this Release and any payment or consideration made in connection with it are not, and shall not be construed as, an admission of liability, fault, or wrongdoing by any party, but are made solely for the purpose of compromising disputed claims and avoiding litigation.

8. MEDICAL TREATMENT

I received medical treatment in connection with the Incident.

9. NOTICES

All notices required or permitted under this Release shall be in writing and delivered to the address provided above by personal delivery, nationally recognized overnight courier, or certified mail, return receipt requested, and shall be deemed given on the date of receipt.

10. GOVERNING LAW; VENUE

This Release shall be governed by and construed in accordance with the laws of the State of without regard to conflict of law principles. The parties submit to the exclusive jurisdiction of the state and federal courts located in that State for any dispute arising under this Release.

11. ENTIRE AGREEMENT; SEVERABILITY

This Release constitutes the entire agreement between the parties with respect to the subject matter hereof and supersedes all prior and contemporaneous agreements, understandings, negotiations and discussions, whether oral or written. If any provision of this Release is held to be invalid, illegal or unenforceable, the remaining provisions shall continue in full force and effect.

12. AMENDMENT; WAIVER; COUNTERPARTS

This Release may not be amended or modified except by a writing signed by both parties. No waiver of any provision of this Release will be effective unless in writing and signed by the party waiving compliance. This Release may be executed in counterparts, each of which shall be deemed an original and all of which together shall constitute one and the same instrument.

13. REPRESENTATION REGARDING UNKNOWN CLAIMS

Releasor acknowledges that Releasor may hereafter discover facts different from or in addition to those which Releasor now knows or believes to be true, but that it is Releasor's intent to fully and finally settle all Claims released hereby. Releasor expressly waives any rights Releasor may have under any statute or common law principle that limits the release of unknown claims.

ACKNOWLEDGMENT

Releasor acknowledges that Releasor has read this Release, understands its terms, has had the opportunity to seek independent legal counsel, and is signing voluntarily and without duress.

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