In consideration of one dollar ($1.00) and other valuable considerations to the undersigned paid by the Town of Andover and the Andover School Committee, the receipt whereof is hereby acknowledged, the undersigned hereby remises, releases and forever discharges the said Town and School Committee and all their officers, agents, and employees, and each of them, of and from all debts, demands, actions, causes of action, suits, accounts, covenants, contracts, agreements, damages, and any and all claims, demands and liabilities whatsoever of every name and nature, both in law and in equity, which against the said Town and School Committee and their officers, agents, and employees, and each of them, and their heirs, successors and assigns, the undersigned now has or ever had, and more especially on account of personal injuries which the undersigned may suffer while on school premises.
Witness my hand and seal this ____ day of ________________________, 20___.
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NAME
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STREET
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CITY/TOWN, STATE, ZIP CODE
Signed in the presence of:
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NAME
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STREET
___________________________________
CITY/TOWN, STATE, ZIP CODE
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DATE