SHENANDOAH MARLINS AQUATIC CLUB

Permission For A Licensed Massage Therapist 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 ________________________________________ (massage therapist or other certified professional), to provide a massage, rubdown and/or athletic training modality on ________________________________________(minor athlete)  on __________(date ) on ________________________________________ (location).The massage, rubdown or athletic training modality must be done with at least one other adult present in the room and must never be done with only ________________________________________minor athlete and ________________________________________ (massage therapist or other certified professional) in the room.

I acknowledge that I have the right to observe the massage, rubdown or athletic training modality. I further acknowledge that this written permission is valid only for the dates and location specified herein.

Legal Guardian Signature:                            

Date: