Receipt Release and Indemnity Agreement

RECEIPT, RELEASE AND INDEMNITY AGREEMENT

STATE OF LOUISIANA

PARISH OF

BE IT KNOWN, that on this day of 20 before me,

the undersigned Notary, personally came and appeared:

INDIVIDUALLY AND AS ADMINISTRATOR OF THE

ESTATE OF HIS MINOR CHILD,

of the full age of majority and domiciled in the Parish of State of Louisiana,

who, upon being duly sworn, did depose and say that he is the plaintiff in the matter styled,

“ v. ”, Suit No. , “ Division _”, on the docket

of the Judicial District Court, State of Louisiana, in and for the Parish of

State of Louisiana, which suit asserts a cause of action, which occurred on

or about , 20, whereby the minor, sustained injuries

playing with another minor child, in a spacewalk at a party hosted by

and and which injuries are alleged to have caused

plaintiff to suffer personal injuries, incur medical expenses and potentially lost wages. Appearer

understands that all of the defendants in the said suit expressly deny that they are in any way

liable for any damages, but it is nevertheless Appearer's desire to compromise and settle said

claim and any and all controversies and claims which Appearer has or may claim to have against

and Individually and as the Tutrix

and Administratix of the Estate of her minor child, and

in said suit, received or sustained at any other time or place as a result of

said incident, Appearer understanding that if he were to have the aforesaid suit tried in a court of

law that he might receive more money, but that he would also run the risk of receiving less or

none whatsoever (it being acknowledged this is a partial release and all rights are reserved

against all remaining defendants in the litigation).

NOW THEREFORE, for and in consideration of the sum of

AND NO/100 ($) DOLLARS cash in hand paid to Appearer by

plus the costs of this suit through partial dismissal as to the released defendants, the receipt of

which is hereby acknowledged, and there being no promise or agreement for further

consideration or any sort, the aforesaid controversies and claims are hereby compromised and

settled, and Appearer, for himself, his heirs and assigns, and on behalf of his minor son, does

expressly release and forever discharge and

Individually and as the Tutrix and Administratix of the Estate of her minor

child, , and their insurers,

affiliates, parents, successors, assigns, heirs, subsidiaries, agents, employees, representatives,

officers and related entities, and all other persons for whom the above parties might be held

responsible, from any and all claims for damages arising out of or in any way connected with the

previously described incident, and any and all injuries, costs, expenses or damages sustained by

Appearer or his minor son as a result thereof, at or about the time and place stated above, or at

any other time or place, irrespective of how the same may have arisen, or under what laws; and,

Appearer hereby acknowledges for himself, his heirs and assigns, as well as his minor son, full

and final satisfaction therefore. Appearer expressly reserves any and all of his rights and causes

of action against the remaining defendants, d/b/a

, and their insurer, .

Appearer now declares to me, Notary, and the undersigned witnesses, that he understands

that this compromise concludes the aforesaid suit as against the released parties and that he does

hereby instruct his attorney, , to dismiss, with prejudice, as to the claim of

“ v. ”, Suit No. , Division “_”, said suit

which now stands on the docket of the Judicial District Court, State of Louisiana, in and

for the Parish of against the released parties only (reserving all rights

against the remaining defendants in this litigation).

Appearer finally declares to me, Notary, and the undersigned witnesses, that this release

is made and executed by him of his own free will; that he knows all of the facts and rights in

connection herewith; the same having been explained to him by his aforesaid attorney; and, that

he has not been influenced or induced to make this compromise settlement as a result of any act

or action on the part of any employee, agent, or attorney for any of the parties in whose favor this

release is executed.

THE UNDERSIGNED hereby convenants and agrees to defend, indemnify and hold

harmless the persons and entities herein released in the event that any other claims, arising out of

the incident described above, are asserted by or on behalf of anyone against any of the parties

released herein. More specifically, affiant agrees to defend, hold harmless and indemnify the

released parties from any liability related to medical liens, subrogation claims or loss of

consortium claims which have been asserted or might be asserted in the future.

THUS DONE AND SIGNED on the date first above mentioned after a due reading of the

whole in the presence of the undersigned witnesses:

WITNESSES: