Authorization for Emergency Medical Treatment

What Triangle location do you and/or your loved one attend?*

450 Broadway, Malden493 Main Street (Prism Program), Malden157 Pleasant Street, MaldenRandolphSalem
Definition of Forms
- Authorization for Emergency Medical Treatment: This needs to be completed by the guardian.
  - If an individual is presumed competent, they need to sign/complete this form.

Authorization for Emergency Medical Treatment
I, First Name Last Name give Triangle, Inc. my permission to perform First Aid/CPR and or obtain medical assistance in the event that Name becomes injured or becomes ill.
Yo, First Name Last Name doy a Triangle, Inc. mi permiso para realizar primeros auxilios/RCP y/o obtener asistencia médica en caso de que Name se lesione o se enferme.
I give my consent voluntarily, without threat of punishment or promise of reward. I have discussed this release with the person obtaining my consent and have had my questions fully answered. I understand that I may withdraw my consent at any time without fear of punishment.
Individual's signature

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Guardian's signature (if necessary)

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Signature of person obtaining consent

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