Release and Indemnity Agreement

Release and Indemnity Agreement

_________________________ Clerk. County

Rec. In Bk. _____ Pg. ______

KNOW ALL MEN BY THESE PRESENTS, that for and in consideration of the total sum of TEN THOUSAND DOLLARS ($10,000.00), paid to us by and on behalf of the parties hereby released, for the use and benefit of , a Minor, the receipt and sufficiency of which is hereby confessed and acknowledged, and paid to us in our capacity as natural parents and next friends of , a Minor, and pursuant to the authority of that certain Decree of the Court of County, rendered on the day of , 20___; in that certain Cause Numbered on the General Docket of said Court, and for and in consideration of the total sum of EIGHT THOUSAND AND NO/100 DOLLARS ($8,000.00) paid to us by and on behalf of the parties hereby released, the receipt and sufficiency of which is hereby confessed and acknowledged, and paid to us in our individual capacities, we, the undersigned and , individually and as natural parents and next friends of , a Minor, have for said Minor and do by these presents in our individual capacities and in the capacity as natural parents and next friends of said Minor, hereby release and forever discharge and , along with their heirs, executors, executrixes, administrators, administratrixes, agents, assigns, employees, employers, associated companies, and any and all other persons, associations, partnerships, or corporations associated with or related to the parties hereby released, none of whom admit any liability and all of whom expressly deny liability, from any and all claims, demands, damages, actions, and causes of action, of every kind and nature, whatsoever, and particularly on account of any and all claims, known and unknown, which the said Minor and we the undersigned, or any of them, have against the above referred to parties as a result of or in any way growing out of that certain accident which occurred on or about , 20____, wherein said Minor received injuries.

In order to obtain the compromise settlement hereinabove set out and as a further inducement to the above referred to parties to make the same, we, and , natural parents and next friends of said Minor, do hereby individually release and forever discharge said parties from any and all liability to us on account of the injuries and damages sustained by , a Minor, in the accident hereinabove described, and on account of all damages of every kind and character sustained by us, including loss of consortium, on account of or in any way growing out of said accident, even though such damages and expenses may be now unanticipated, unexpected or unknown, as well as any and all damages and losses which have already developed.

Full accord and satisfaction are hereby acknowledged, and it is expressly agreed by the undersigned never to sue the parties hereby released on any alleged promise or inducement for this Release not herein expressly set forth. We further warrant that no promises or inducements not herein expressed have been made to us and that in executing this release we are not relying upon any statement or representation made by any party or parties released, or by their agents or representatives, concerning the nature, extent or duration of the losses or damages sustained by , a Minor, or ourselves, or of the legal liability therefore, or concerning any other thing or matter.

We further understand that this Release is executed pursuant to a compromise settlement and that its effect is to forever terminate all claims of every kind which the Minor, ourselves, or any other person associated with us, may have against the parties hereby released, or any associated person or company, on account of the injuries and damages sustained by , a Minor, or ourselves, as a result of the accident hereinabove described. It is understood that payment of money as specified in this Release is not to be construed as an admission of liability on the part of Releasees.

For the same consideration aforesaid, the undersigned do hereby covenant that all medical bills or expenses of any kind or nature arising out of the accident aforedescribed that have been paid or will be paid by , or by any other person or entity whatsoever, that has a right to claim for reimbursement of payment of said medical bills or expenses from the party or parties being hereby released, as a result of the accident hereinabove described, will be paid by us so that we alone retain all rights with regard to such actions and damages. No other person, association, partnership or corporation possesses a right of subrogation against the parties hereby released. The undersigned has not transferred, in whole or in part, any right, claim, demand or cause of action which the undersigned might have or claim to have against Releasees on account of or as a result of the aforesaid incident. The undersigned acknowledges that all future medical expenses of any kind for said minor will be their sole responsibility.

We further agree to hold harmless and indemnify and , along with their heirs, executors, executrixes, administrators, administratrixes, successors, agents, assigns, employees, employers, associated companies, and any and all other persons, corporations, and partnerships, associated with them, from any and all claims and demands, actions and causes of action, costs and damages, to include the payment of attorney's fees, which might be incurred in the defense of any claim made by any person, claiming by and through , a Minor, or ourselves, for medical bills and expenses or any other damages arising out of the previously described accident.

It is specifically understood that settlement of the Minor's claim, and the $10,000.00 tendered herein for such settlement, is to be for the use and benefit of , a Minor, pursuant to the above referenced Decree of the Court of County, .

We further, by our signatures hereto, acknowledge that we have read and understand the provisions of this Release and that same have been explained to us by counsel of our own choosing.

WITNESS our signatures on this the day of 20___.

STATE OF

COUNTY OF

PERSONALLY appeared before me, the undersigned authority at law in and for the state and county aforesaid, , who after being by me first duly sworn stated under oath that the matters and things contained in the above and foregoing document are true and correct as therein stated, to the best of my knowledge, information and belief.

SWORN TO AND SUBSCRIBED before me, this the day of 20___.

__________________________

NOTARY PUBLIC

My Commission Expires:

STATE OF

COUNTY OF

PERSONALLY appeared before me, the undersigned authority at law in and for the state and county aforesaid, , who after being by me first duly sworn stated under oath that the matters and things contained in the above and foregoing document are true and correct as therein stated, to the best of my knowledge, information and belief.

SWORN TO AND SUBSCRIBED before me, this the day of 20____.

_______________________

NOTARY PUBLIC

My Commission Expires:

READ AND APPROVED:

ATTORNEY FOR AND