Fill and Sign the Waiver and Release of Personal Injury Claim Form

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 - 1 - 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 representing them concerning the nature, extent or duration of the damages or losses, or the legal liability therefore. It is understood and agreed that this release is executed and delivered, and the sum of money hereinabove specified is paid, as the compromise and settlement of a doubtful and disputed claim. The payment of this money is not to be construed as an admission of liability on the part of the Releasees, but on the other hand, the Releasees specifically deny any such liability therefore. The undersigned further certify he/she is completely competent or authorized to execute this release and that she/he has fully read and completely understood the same or have had it explained to them. In further consideration of such payment, the undersigned do hereby covenant and agree to forever refrain and desist from instituting, prosecuting or asserting against the Releasees named hereinabove, and any and all other persons, firms, organizations and/or corporations whatsoever having any liability in the premises, any claim, demand, action or suit of whatever kind or nature, either directly or indirectly, for injuries or damages of any kind whatsoever, resulting or to result in any manner whatsoever from the aforesaid including all expenses necessarily incurred and resulting therefrom, past, present and future. The undersigned further covenant that all medical, funeral, hospital, doctor, drug and other bills incurred on account of the aforesaid injury have been paid in full, or will be paid immediately by the undersigned; and the undersigned covenant and warrant that there have been no assignments or subrogation of any claim or right in the premises to anyone not joining in this - 2 - release, and the covenants, warranties and guaranties contained herein apply to all persons, individually and in his/her representative capacity, and in every regard whatsoever; and the undersigned agree that, hereafter, the released parties are and shall be forever free of liability. This release contains the entire agreement between the parties hereto and the terms of the release are contractual and not a mere recital. Should it develop that there are any mistakes in this instrument which cause the release of the releasees to be defective or less than complete, the undersigned, will execute any and all instruments and do any and all things necessary to effectuate a full, final and complete release. This release shall be construed according to, and the rights and liabilities of the persons or entities named herein shall be governed by the laws of ______________. WITNESS MY SIGNATURE, this the ____ day of ______________, 20__. _________________________________ STATE OF _____________________ COUNTY OF ____________________ PERSONALLY APPEARED before me, the undersigned authority in and for the jurisdiction aforesaid, the within named _____________________who acknowledged that she signed and delivered the foregoing instrument on the day and year therein mentioned and for the - 3 - purposes therein set forth. GIVEN under my hand and official seal, this the ____ day of _______________, 20__. _________________________________ NOTARY PUBLIC My Commission Expires: - 4 -