Medical Release and Authorization
(Effective Sept 1, 2024-Aug. 31, 2025)
I hereby give my permission to the physician or dentist selected by New Life Church of the Nazarene, Wheeler, Wisconsin, to hospitalize, to secure proper treatment and/or order an injection, anesthesia or surgery for my child(ren) as
deemed necessary, after every attempt to contact the parent, guardian and/or other emergency contact has failed.
I further agree that I am fully responsible to pay all charges and expenses relating
to such care and treatment. My signature below serves to indicate my willingness for my Health Insurance Company to be billed for any and all medical fees and services should they be needed. I agree that I will pay all charges and expenses not covered by my insurance. My signature below also serves as a medical release for the above mentioned child(ren).