Release by Parent on Behalf of Child for Injuries Sustained in Accident

Release by Parent on Behalf of Child for Injuries Sustained in Accident Prior to Suit Being Filed

Release executed on by of individually and as Parent and Guardian of said Parent and Guardian being hereinafter called the Releasor, in favor of of hereinafter called the Releasee.

Whereas, on or about an accident occurred, resulting in bodily injuries to 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 .

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 .

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 , Individually and as the Parent and Guardian of , who acknowledged that he executed the above and foregoing instrument.

My Commission Expires: