Fill and Sign the Harmless Form Sample

Surrogate Release and Hold Harmless Agreement Agreement made on the _______ day of __________________ , 20 _______ , between _____________________________ (Name of Surrogate) of _____________________________________________ (street address, city, county, state, zip code) , referred to herein as Surrogate , _____________________________ (Name of Spouse of Surrogate) , of _____________________________________________ (street address, city, county, state, zip code) , referred to herein as Husband, and _________________________ (Name of Attorney), of _____________________________________________ (street address, city, county, state, zip code) , referred to herein as Attorney; Whereas, Surrogate and Husband have applied to Attorney to act as a surrogate to bear a child for _____________________________________________ (Names); and Whereas, it is Surrogate’s desire to enter into a fee paid Surrogate Parenting Agreement where Surrogate will be artificially inseminated by a physician for the purpose of becoming pregnant; and Whereas, upon birth of the child, Surrogate and Husband will surrender custody rights to the child in favor of _____________________________________________ (Names), and where necessary and permitted by law, terminate all parental rights to the child. Now, therefore, for and in consideration of the mutual covenants contained in this Agreement, and other good and valuable consideration, the receipt and sufficiency of which is hereby acknowledged, the parties agree as follows: 1. Surrogate represents that she is healthy, both physically and mentally, and is capable to the best of her knowledge of conceiving and carrying a fetus to term. 2. Surrogate and Husband, represent that they were married on ______________ (date), and have cohabited together as man and wife since that date. 3. Surrogate and Husband understand that several attempts at artificial insemination may be necessary, and that Attorney does not guarantee that pregnancy or full term pregnancy will result from artificial insemination. Surrogate and Husband have been advised and counseled as to the potential psychological implications on their marital and family relationship that may result from the birth of a child through this surrogate parenting procedure. 4. Under no circumstances shall Surrogate or Husband require that the identity of Surrogate or Husband be divulged to the child or to anyone else, and accordingly, forever waive all rights, if any, that Surrogate or Husband may have as to the identity, address, or any other information whatsoever concerning the Surrogate and Husband. 5. Husband and Surrogate recognize that surrogate parenting is a relatively new procedure,that the laws are unclear in many areas, and they have therefore retained their own independent legal advisor. 6. Husband and Surrogate hereby release Attorney at from any and all liability and responsibility of any nature whatsoever which may result from the complications of childbirth or delivery, or from the birth of an infant abnormal in any respect, or from the hereditary tendencies of that issue, or from any adverse consequences which may arise in connection with, or as a result of the artificial insemination. WITNESS our signatures as of the day and date first above stated. ________________________ _________________________ (Signature of Surrogate) (Signature of Husband) ________________________ ________________________ (P rinted Name of Surrogate) (Printed Name of Husband )