Fill and Sign the Itelease and Indemnity Agreement Recitals Form

- 1 - RELEASE OF PERSONAL INJURY CLAIM KNOW ALL MEN BY THESE PRESENTS that I, the undersigned, for and in consideration of the total sum of_________________ and no/100 Dollars ($___________), for all injuries and damages to the undersigned arising out of the following: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ does hereby remise, release and forever discharge ______________ and their insurers, heirs, estates, successors, representatives, assigns, employers, employees, principals, associates, and any and all other persons, firms, organizations and/or corporations who are in privity therewith whatsoever having any interest or liability in the premises, they being hereinafter designated as the "Releasees", either directly or indirectly, of and from any and all actions, causes of action, claims, demands, losses, injuries, expenses and damages of every type, kind and character whatsoever which have heretofore been sustained or which may hereafter be sustained as a result of the above described. This consideration is hereby acknowledged by the undersigned to be paid to and received by in full and complete compromise, settlement, accord and satisfaction therefore. In executing and delivering this release, the undersigned rely wholly upon his/her own judgment, knowledge and belief as to the nature, extent and duration of the damage which he/she may have suffered or sustained, or may sustain in the future, as a result of the transaction, occurrence or event. As to the questions of liability involved, the undersigned have exercised his/her right to legal counsel. The undersigned further represent and warrant that he/she has not been influenced by any representations, statements, or warranties made by any person, firm, association, partnership or corporation hereby released, or by any agent or other person representin
Ig a released of the releasees of the above, or by any attorney, mediator, mediator's agent or any other representative of a releasee of the above. I have performed the above as the undersigned did and in the manner directed, under the circumstances. The undersigned hereby certifies that I am a citizen of the united states and am an American citizen or qualified as such, or am a citizen of and entitled to hold citizenship according to the provisions of the constitution and laws of the United States and are at the time of such signing under the influence of or induced by the influence of any drug or substance, or under the influence of any intoxicating or mind-numbing substance (as defined in the above statute and section). 1. (a) (b) 2. This agreement and the release contain additional terms and conditions which i will require be incorporated by reference and that are to be effective upon my signature below. These additional terms and conditions may be modified by me and are binding on me and my heirs, assigns, administrators, executors, administrators, successors and permitted assigns. 3. If I fail, or if i misstate my intention as to any material term or condition herein, then the releasing parties are entitled to withdraw from me the benefit of this agreement and of any and all claims I may have under this agreement. 4. If i do not give my prior written approval to any modification and such agreement and claims I may have under this agreement are not withdrawn, then at my option and the option of each released, i consent to the terms and conditions of any such modifications and to the performance of any and all of its conditions. 5. The released or his/her representative, successor or authorized assigns shall bear sole responsibility before any court for the enforcement of this release. 6. These releases, their officers and agents may not be held liable with respect to the fulfillment of or otherwise in any manner effecting any other of the terms and conditions expressed herein. 7. The above agreement shall be and continue in effect forever, unless terminated in accordance with this section. 8. The terms and conditions herein are effective until midnight of the thirtieth day after this agreement is signed. If prior to midnight of the thirtieth day after this agreement is signed, I fail to complete the terms and conditions herein, then my obligations under these releases are suspended until midnight of the thirtieth day after this agreement is signed. If I have