MAINLAND CHRISTIAN SCHOOL

3210 I-45 North

Texas City, Texas 77591

(409) 986-4418

Medical Treatment Release

I/We, ________________________________________________________________________, Soc. Sec. # ______ - ______ - ______ (of insured parent) parents (legal guardians) of _________________________________, address _____________________________________

(city) __________________________ (state) ________ (zip) ________________,

home phone ______ - ______ - __________, hereby give our legal consent and permission to the representatives of Mainland Christian School to seek and obtain any medical care and/or treatment for said child, while the child is in their care. They also have our full consent and permission to sign authorization forms necessary to obtain this medical care and/or treatment.

_______________________________________ ____________________

Signature of Father/Legal Guardian Date

______________________________________________ ________________________

Signature of Mother/Legal Guardian Date

Rev. 2/04