Fill and Sign the Parent Behalf Form

Release by Parent on Behalf of Child for Injuries Sustained in Accident Prior to Suit Being Filed Release executed on __________________ (date) , by ______________________ (Name of Parent and Guardian) , of _______________________________________________ ________________________________ (street address, city, state, zip code) , individually and as Parent and Guardian of _______________________ (Name of Minor) , said Parent and Guardian being hereinafter called the Releasor , in favor of _________________________ (Name of Releasee) of _________________________________________________________ __________________ (street address, city, state, zip code) , hereinafter called the Releasee . Whereas, on or about _________________ (date) , an accident occurred, resulting in bodily injuries to ___________________ (Name of Minor) , a minor, _____ years of age (the Minor ); and Whereas, the Minor is the child of Releasor and Releasor is the legal guardian of the Minor; and Whereas, Releasor has made claims against Releasee for money compensation for the injuries resulting from the accident described above; and Whereas, a dispute has arisen with respect to the legal liability for the injuries and Releasee expressly denies liability; Now, therefore, for and in consideration of the promise to pay $___________ upon Court approval as described below, 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. Releasor releases and forever discharges Releasee and his successors and assigns, heirs, executors, administrators and personal representatives of and from any and all claims, demands, rights, or causes of action of whatsoever kind or nature, arising from, or by reason of, any and all known or unknown, foreseen or unforeseen bodily or personal injuries, damage to property, which to this point in time have been, or which subsequently may be, sustained by the Minor or by the Releasor, or by any other person or persons having a legal interest in the circumstances surrounding the accident or resulting injuries. 2. Releasor agrees, in consideration of the payment specified above, to indemnify and hold forever harmless Releasee and his successors and assigns, heirs, executors, administrators and personal representatives against loss from any and all further claims, demands or actions in law or in equity that may subsequently be made or brought by the Minor or by anyone on behalf of the Minor for the purpose of enforcing a further claim for damages on account of the injuries sustained in consequence of the accident, and Releasor waives any and all rights of exemption, both as to real and personal property, to which Releasor may be entitled under the laws of this state as against a claim for reimbursement or indemnity. 3. Releasor and Releasee agree that this Release will not become effective unless and until it is approved by the ______________________________________ (Name of Court that handles matters involving minors) . 4. In this Agreement, any reference to a party includes that party's heirs, executors, administrators, successors and assigns, singular includes plural and masculine includes feminine. Witness my signature this the _____ day of _______________, 20______. __________________________ (Printed Name of Releasor) __________________________ (Signature of Releasor) Individually and as Parent and Guardian of __________________ (Name of Minor) Acknowledgment may vary by state STATE OF ___________________ COUNTY OF _______________ Personally appeared before me, the undersigned authority in and for the said County and State, on this _____ day of ________________, 20____, within my jurisdiction, the within- named _____________________ (Name of Parent and Guardian) , Individually and as the Parent and Guardian of ____________________ (Name of Minor) , who acknowledged that he executed the above and foregoing instrument. ___________________________________ NOTARY PUBLIC My Commission Expires: ______________________