Release of Hospital and Physician

RITUAL CIRCUMCISION

We, _________ and _____________ (names), of _____________ (complete address), request that ______________ (name of physician), the attending physician, and ______________ (name of hospital), located at _________ (address), permit our son, _________, born ____ (date), to be circumcised by __________ (name of person to perform circumcision), whom we have selected as a person qualified in the ritual of our faith and by experience to perform this procedure. We assume full responsibility for the performance of this procedure on our son, __________, and hereby release _______ (attending physician) and ____________ (name of hospital), its staff and any and all other persons, firms, partnerships and corporations that are or might be claimed to be liable, from all claims of whatever nature, known or unknown, including, without limitation, claims for personal injury and disability, pain, suffering, and mental anguish that may arise from the performance of the above-described procedure.

Dated: _____, at _____ (time).

______________________________

______________________________

(Signatures)

Executed in the presence of:

______________________________

______________________________

______________________________

(Signatures of witnesses, with names and addresses indicated for each person)