Release for Personal Injury
Releasor:	____________________
Address:	____________________
____________________
Releasee:	____________________
Address:	____________________
____________________
1. Releasor voluntarily and knowingly executes this release with the intention of eliminating Releasee's liabilities and obligations as described below.
2. Releasor hereby releases Releasee from all liability for claims, known and unknown, arising from injuries, mental, and physical, sustained by Releasor as follows: __________________. Releasor understands that, as to claims that are known to the parties when the release is signed, any statutory provisions that would otherwise apply to limit this general release are hereby waived. Releasor also understands that this release extends to claims arising out of this incident that are not known by Releasor at the time this release is signed.
3. Releasor has been examined by a licensed physician or other health care professional competent to diagnose: [choose one or both]
[   ] physical injuries and disabilities.
[   ] mental and emotional injuries and disabilities.
Releasor has been informed by this physician or health care professional that the injury described in Clause 2 has completely healed without causing permanent damage.
4. By executing this release Releasor does not give up any claim that he or she may now or hereafter have against any person, firm or corporation other than Releasee and those persons specified in Clause 7.
5. Releasor understands that Releasee does not, by providing the value described in Clause 6 below, admit any liability or responsibility for the above described injury or its consequences.
6. Releasor has received good and adequate value (consideration) for this release in the form of: ____________________.
7. By signing this release, Releasor additionally intends to bind his or her spouse, heirs, legal representatives, assigns, and anyone else claiming under him or her. Releasor has not assigned any claim arising from the accident described in Clause 2 to any other party. This release applies to Releasee's heirs, legal representatives, insurers, and successors, as well as to Releasee.

_____________________________________________	__________________
Releasor's signature	Date

_____________________________________________	__________________
Print name	County of residence

_____________________________________________	__________________
Releasor's spouse's signature	Date

_____________________________________________	__________________
Print name	County of residence

_____________________________________________	__________________
Releasee's signature	Date

_____________________________________________	__________________
Print name	County of residence

_____________________________________________	__________________
Releasee's spouse's signature	Date

_____________________________________________	__________________
Print name	County of residence

Certificate of Acknowledgment of Notary Public

State of _______________________________	)
	)	ss
County of _____________________________	)

On _____________________, before me, ______________________________, a notary public in and for said state personally appeared ___________________ ________________________, known to me (or proved to me on the basis of satisfactory evidence) to be the person whose name is subscribed to the within instrument, and acknowledged to me that he or she executed the same in his or her authorized capacity and that by his or her signature on the instrument, the person, or the entity upon behalf of which the person acted, executed the instrument.
	WITNESS my hand and official seal.
	_____________________________________
	Notary Public for the State of ______________
	My commission expires __________________
[NOTARY SEAL]