SHENANDOAH MARLINS AQUATIC CLUB

Permission For A Certified Professional Or Health Care Provider To Treat A Minor Athlete

I, ________________________________________, legal guardian of ________________________________________, a minor athlete give express written permission, and grant an exception to the Minor Athlete Abuse Prevention Policy for a mental health care professional and/or health care provider, to have a one-on-one interaction with  ________________________________________(minor athlete)  in conjunction with participation in the sport of swimming  on __________ (date) from __________am/pm to __________am/pm.

I acknowledge that this one-on-one interaction may be a closed-door meeting, provided that the door remains unlocked; another adult is present at the facility; and the other adult at the facility is advised that a closed-door meeting is occurring. I further acknowledge that this written permission is valid only for the dates and location specified herein.

Legal Guardian Signature:                            

Date: