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Midland Evangelical

Free Church

Sunday Worship 9:00 & 10:45 AM

The Portal

LTAMC and MEAP

Below are two separate forms;the Midland Evangelical Free Life Threatening Allergy & Medical Condition Form (LTAMC) and the Midland Evangelical Free Church Medical Equipment Administration Permission Form (MEAP). Please complete the LTAMC at a minimum, and the MEAP if needed. An electronic signature is required for each form.

Please fill out the following 4 fields for you, the adult filling out the form:


Midland Evangelical Free Church 
Life Threatening Allergy & Medical Condition Form (LTAMC)
*Child's Full Name:
*Child's Date of Birth:
*Class/Grade/Age:
Mother's Full Name:
Mother's Cell Phone:
Father's Full Name:
Father's Cell Phone:
Legal Guardian's Name:
Legal Guardian's Cell Phone:
*Allergy and/or Medical condition(s):
*Type(s) of reaction:
*Please select which applies:
By signing below I acknowledge I have read and understand Midland Free's LTAMC Form and agree to release, indemnify and hold harmless Midland Free and any of its staff, volunteers or agents from lawsuit, claim, expense, demand or action against them.
*Parent/ Guardian Electronic Signature:
If a copy of this agreement is needed please contact the MEFC office at 989-631-4411.

(If applicable, complete the MEAP below. If not, continue to the bottom of the page and click "Submit Form").


Midland Evangelical Free Church 
Medical Equipment Administration Permission Form (MEAP) 
*Child's Name as it appears on prescription:
*Authorized Medical Equipment (list EpiPen, Inhaler, or Other and describe):
*Please select one:
*By signing below I hereby authorize the staff, volunteers, and agents at Midland Evangelical Free Church (Midland Free) to assist in administering the Authorized Medical Equipment (Equipment) to my child if he/she has known exposure and/or a severe allergic reaction. If my child is not able to administer their Equipment on their own, I agree to allow the administration of the Equipment by Midland Free. I agree to release, indemnify, and hold harmless Midland Free and any of its staff, volunteers, or agents from lawsuit, claim, expense, demand, or action against them for administering the Equipment provided they administer the Equipment prescribed specifically for my child. I am aware that the Equipment will most likely be administered by a staff member, volunteer, or agent who is not a healthcare professional. I have read the MEAP Form and agree to provide Equipment as needed. I understand I will be notified as quickly as possible anytime my child's Equipment has been administered. If an EpiPen is used, 911 will be called for further medical attention.
*Parent/ Guardian Electronic Signature:
If a copy of this agreement is needed please contact the MEFC office at 989-631-4411.

The below field is for use by safety staff, please leave blank.
Staff Notes: