THE INFLUENCE OF PEER PRESSURE IN FORMING

THE SELF-IDENTITY: A CASE STUDY

ANALYSIS ON ADOLESCENT

In Partial Fulfilment of the Requirements in

Related Learning Experiences
RLE 107

Presented to:
Paula P. Leanillo, AB, RN, MN

By:

Anna Larita
BSN-2A

October, 2020
 CHAPTER I

INTRODUCTION

This chapter contains the Introduction of the study in which it contains the Background

of the Study, Purpose of the Study, Theoretical Lens, Limitation and Delimitation of the study,

and Definition of Terms used.

BACKGROUND OF THE STUDY

Adolescence is an individual that is transitory as this developmental stage is in a process

of developing in becoming an adult and often seen to experience peer pressure as they often seek

comfort among their peers and unknowingly follow what their peer does either if it has a good or

bad effect for them (Adeniyi & Kolawole, 2015). As children develops and reach adolescent

stage, teenagers become more dependent with their circle of friends or peers than their family as

they feel much more comfortable with them as evidenced by being dependent on decision

making and enhancing moral values in life with their peers (Uslu, 2013).

A sample conducted from 689 adolescents particularly in grades 7–12 from two

Midwestern communities and identified as a member of three major peer groups responded to

the self-reported survey of the study aiming to assess the multi-dimensionality of peer pressure

by measuring the perceptions of peer pressure in five areas of behavior: involvement with peers,

school involvement, family involvement, conformity to peer norms, and misconduct. Findings

have shown that perceived pressures to peer involvement were stronger than the other areas,

whereas peer pressures concerning misconduct were relatively uncertain. Results presented the

process of peer influence in adolescent socialization and identity development of adolescents

(Clasen, & Brown, 1985).

In the Philippines, study conducted among 96 respondents in senior high school in

assessing peer pressure clustered in four different categories: social belongingness, curiosity,

cultural-parenting orientation of parents and education. As the researchers believe that

adolescents are susceptible to experience peer-pressure as they are expected to encounter

these phenomena and may optimistically cope with the impact whether to use this as a

positive or negative approach. The result would show the correlation between the perceived

level of peer pressure in terms of social belongingness, curiosity, cultural-parenting orientation of

parents and education (Moldes, Biton, Gonzaga, & Moneva, 2019)..

In Tagum, Davao del Norte, a 17-year old child is being studied on the behaviour

regarding their development with association to peer pressure in forming self-identity and its

effects. The parents of said adolescent were said to have a problem in disciplining the child as it

doesn’t listen to them. The adolescent was said to be always hanging out with his friends in their

neighborhood and tends to portray the attitude that his friends possess. Upon this, the

nurse/researcher decided to analyse a relation between the behaviour of the adolescent and the

peer pressure as its underlying cause.

PURPOSE OF THE STUDY

The purpose of this study was to understand the relation of peer influence in forming the

self-identity of the adolescent and its possible effects in the development. In line with this, the

researcher would like to understand the underlying factor of the behaviour showed by the

adolescent and formulate an effective and therapeutic nursing care plan to address this problem.

THEORETICAL LENS

The following theories are derived as a basis for the nursing care in the study:

Erikson’s theory of Psychosocial Development particularly in the fifth stage of

ego, Identity Vs. Confusion. As this stage experience conflict on developing a personal identity

since adolescents are likely to explore and develop a sense of self. This happens approximately

in between the ages of 12 to 18 during adolescence.

 Hildegard Peplau’s Theory of Interpersonal Relations highlights the importance

of forming a productive partnership between the nurse and patient. Nurses are expected to be

effective in providing therapeutic interventions by building mutual respect for one another.

Idea Jean Orlando’s Nursing Process Theory explains that nurses must avoid

drawing conclusions without the process of assessing and understanding the patient’s situation

as patients have their own meanings and interpretations of situations. Nurses must formulate an

effective nursing care plan and learn to adapt changes considering the complexity comes up with

patient.

DEFINITION OF TERMS

For the purpose of clarification, the important terms in this study have been defined. The

following terms are:

Adolescent. Adolescence is the period of transition between childhood and adulthood.

Children who are entering adolescence are going through many changes (physical, intellectual,

personality and social developmental). 

 https://my.clevelandclinic.org/health/articles/7060-adolescent-development

Self- Identity. Self-identity is a combination of personality traits, abilities, physical attributes,

interests, hobbies, and/or social roles from your personal identity that you specifically identify

yourself.

 https://destinysodyssey.com/personal-development/self-development-2/self-concepts-

self-constructs/self-identity/

Peer pressure. Peer pressure is when you are influenced by other people (your peers) to act in

a certain way. 

 https://study.com/academy/lesson/what-is-peer-pressure-definition-lesson-quiz.html
LIMITATION AND DELIMITATION OF THE STUDY

This study is limited to the assessment of adolescents living within the community of the

nursing student/researcher conducting this study due to the COVID-19 situation. This study

delimits to the assessment of a 17-year old Adolescent's developmental growth to formulate

nursing care plan and provide interventions in addressing patient’s needs. The data was

gathered from the patient at Capitol Homes Subdivision, Mankilam, Tagum City with the

consent of the Mother and the Adolescent.

 CHAPTER II

REVIEW OF RELATED LITERATURE

This chapter presents the journal reading done by the researcher which contains the

relevant topics surrounding the subject of the study. It contains Adolescence, Bullying,

Aggression in Adolescents, Effects of Videogames in Adolescents, Effects of Sleeping Late in

Adolescents, Food Allergies and the summary and reflection of the journal reading.

Adolescence as developmental period

Adolescence frequently associate with puberty as a phenomenon in which our body

undergoes constellation of events driven by hormonal changes such as increase of adrenal and

gonadal hormones, including physiological changes as development of secondary sex

characteristics and modulations in muscle fat (Dahl, 2004). This period of development

coincident with the changes in behaviour as spending time with peers are more than spending

time with the family, as well as an increase in autonomy (Jaworska, & MacQueen, 2015). As

achieving autonomy, generally considered as an essential normative psychosocial task and

might be operationalized differently between collectivist and individualist cultures (Zimmer-

Gembeck & Collins, 2003). Adolescents are in search of new identity mostly dependent with

their peers and seek independence from their parents. Adolescents in early period exhibits

heightened self-consciousness, increase instability of self-image and reduction of favorable

opinions of self (Gikonyo, & Njagi, 2020). Brown (2004) citing Steinberg and Silverberg (1986)

states that the adolescents become ideally emotionally autonomous before he or she is ready.

Identity formation in Adolescents

Erikson (1968) stated that identity among adolescents is the main and most important

task as in this stage, adolescent will encounter the identity versus role confusion crisis. The first
occurs called the crisis of identity versus confusion which occurs during early to middle

adolescence, while the second one called intimacy versus isolation occurred during late

adolescence and early adulthood (as cited by Morelli, 2020). The first crisis among adolescence

represents the struggle to “fit in” or finding an area where to stand in developing a unique

individual identity. This explains that youth are determined in what they envisioned themselves

to be and how they want to be seen by others (Morelli, 2020)

Adolescents as they construct their own unique sense of identity, finds an environment

they prefer in order for them to grow and create meaningful relationships and build sense of

belongingness (Chen, Lay, Wu, & Yao, 2007). Physical, cognitive, social, and emotional changes

that takes place during adolescence, questions such as “who am I?” is likely to arise as young

people begins to search for their self-identity. This questions are critical to lifelong pyscho-social

wellbeing and thriving (Arnold, 2017). Identity is often interpreted by others as something to

achieve and considered as a checkmark to move at the other tasks to be done but in the reality,

identity formation, which occurs earnes during the adolescent stage are continuous across

lifespan of an individual as it is a continual cycle of confirmation and appraisal (Côté & Levine,

2016; Eichas et al., 2015).

Peer pressure towards Teenagers

At the time in which physiological, psychological, intellectual, and social changes occur;

these changes will eventually commit adolescents to serious task of becoming an autonomous

individual. The adolescent as they need to have the sense of belongingness into a peer group as it

gives both influence and power, the price of entering and adhering group norms are the

manifestation cost of peer pressure (Clasen & Brown, 1987). Prior research presented that the

continuously development of susceptibility of peer pressure among adolescence following an

inverted U-shaped curve presented that, resistance to peer pressure increases linearly in
between ages 14 and 18. In contrast, little evidenced for growth in this capacity between ages 10

and 14 or between 18 and 30 (Steinberg, & Monahan, 2007).

Individuals seeks emotional support to others to get confirmation and appraisal in

showing his private objectives or goals in communicating publicly as this could give them

benefits emotionally and overcome temptations (Borein & Boemont, 2013). Peer pressure in

relation with person’s behaviour which is said to be social phenomenon are not all interpreted as

negative influence but majority are affected by undesirable behaviour of those people who resist

what others do (Gulati, 2007). Identity development among adolescents is positively related

with the relationships with peers and belonging to a peer group based on mutual respect

(Ragelienė, 2020).
 CHAPTER III

METHODOLOGY

This chapter contains the research methodologies used in the study. This includes the

Study Design, Research Participants & Informants, Data Sources, Data Collection Procedure,

Data Gathering Procedure, and Drug Study.

STUDY DESIGN

This study was conducted using the Qualitative Research Design which according to

Bogdan, & Biklen, (1997), it is the systematic inquiry in natural settings addressing social

phenomena that are not limited to, lived experience of the people, how they behave, how

organizations function, and how this interactions builds relationships with one another. This

design examines what are the causes of the focus or phenomena, why such events occur and

what do they mean to the participant.

RESEARCH PARTICIPANTS AND INFORMANTS

The selected participant in this case study was a 17-year old male adolescent residing in

Capitol Homes Subdivision, Purok Uraya, Barangay Mankilam, Tagum City. The researcher

used purposive sampling in qualitative synthesis, to helped ensure that the study will present

rich data and focused closely to the main objective (Ames, Glenton, & Lewin, 2019) in which

participant was chosen with the criteria that they fit to adolescent age group. The main goal of

this sampling is to focus on particular characteristics that will allow researchers to provide best

answers to research questions (Purposive sampling | Lærd Dissertation., 2020)

DATA SOURCES

The data collected in this study was acquired through interview using an assessment

tool.
In-depth interviewing is known as a research technique that conducts intensive individual

interviews among the research participants and has great advantage to gather more detailed

information about thoughts and behaviours of the participant. This method will allow the

participant and interviewer to build sense of trust with each other ( Boyce & Neale, 2006). The

primary source of data is from the participant and data being gathered was recorded through video

recording and writing.

DATA COLLECTION PROCEDURE

For collecting the data, the researcher first search for a participant aged 13-18 within the

community near the researcher as to comply the safety measures due to Covid-19 pandemic.

After the researcher find the participant that meets all the conditions needed, the researcher will

now then inform the participant along with their guardian about the study that will be

conducted. If the participant and the guardian agree, informed consent containing conditions in

participating will be given and the researcher will now conduct the interview with the use of

phones for video recording and assessment tool to gather information needed.

DATA GATHERING PROCEDURE

The data gathered are presented in this section with the use of Interview & Observation

for Patient Need Assessment as well as the Assessment Tool. Within this section also presents

the school records presented by the mother - however, due to privacy reasons, the name of the

participant will not be shown.

 Assessment Tool
Growth and Development

Name: --- Grade/Year: Grade 9 Age: 17 years old Date of Assessment: Sept. 15, 2020
ASSESSMENT WORKSHEET 1:
PAST HEALTH Hospitalizatio Immunization Illness of Allergies Past Medication Result Conclusion
HISTORY n s Relatives Illness s if any
Regan Completed None None Fever, None Health not No family
hospital: Cough at risk. history of
Amoebiasis and any
Colds diseases
and child’s
health is
managed.
SOCIAL HISTORY Lives with WHO attends Are there Other Assessment Nuclear Living
WHO to needs? members Family Situation is
in the structure common
househol with one with
d who family mother as
smoke? member father is
Lives with Parents Older The children always left home to who smokes working
Mother, brother come to his friends along their but not overseas to
Father, older neighborhood even without parent’s currently provide
brother, two approval. “.. Mugawas mana siya living with financial
sisters and bisag way pananghid” as verbalized them. support
one younger by the mother. with the
brother. family.
NUTRITIONAL Liquid Intake Food Urination Stooling Other Assessment Nutrition is Participant’
ASSESSMENT Preference Habit Habit adequate as s urination
4-5 glasses a Likes all kinds 2-3 times 3 times a Eats multiple snacks evidenced and
day a day day and meals a day by no food stooling
 dislikes that habit is
can cause regular.
undernou-
rishment.
DEVELOPMENT Sleep Pattern Recreational Exercises Study Habit Spiritua Other Participant Participant
AL ASSESSMENT and Amount Activity/Past- Activity and School l Assessmen is able to has
of Sleep time Hobbies Performanc Worshi t have uncommon
e p enough sleep
Activity amount of pattern
Sleeps from 1 Basketball Plays Doesn’t Only The sleep that needs
am or 3 am. Playing basketbal study and goes to adolescent despite to be
Amount of mobile games l with receives church was said to disturbed improved
sleep friends low grades. when be more sleep along with
estimated is ; parents active at pattern. his study
7-8 hours go. night and Participant habits.
Attends always is not active
Praise sleeps in in any
and the school
Worship morning as activities
in verbalized resulting to
Christian by the poor
Life mother. academic
group. performanc
e.

ASSESSMENT WORKSHEET 2

DEVELOPMENTAL NORMAL BASED ON

OBSERVED DATA RESULT INFERENCES
ASSESSMENT REFERENCE
PHYSICAL  Boys may begin to notice that Data Collected as responded by Normal Data collected is
 their testicles and scrotum the participant: Development in accordance
grow as early as age 9. Soon, with normal
the penis begins to lengthen. Height – 5’4 reference. Adam’s
By age 17 or 18, their genitals Weight – 50 kg apple is more
are usually at their adult size prominent and
and shape. - Adams apple is prominent participant’s voice
 Pubic hair growth, as well as -Deep tone of voice is observed is developing into
armpit, leg, chest, and facial a deeper tone.
hair, begins in boys at about
age 12, and reaches adult
patterns at about 17 to 18
years.
 Boys do not start puberty
with a sudden incident, like
the beginning of menstrual
periods in girls. Having
regular nocturnal emissions
(wet dreams) marks the
beginning of puberty in boys.
Wet dreams typically start
between ages 13 and 17. The
average age is about 14 and a
half years.
 Boys' voices change at the
same time as the penis
grows. Nocturnal emissions
occur with the peak of the
height spurt.
 Boys' growth spurt peaks
around age 13 and a half and
slows around age 18.
COGNITIVE Start to set goals for the future - was able to give concrete Normal Data observed is
Plan for “what if” situations answers to question Development in accordance
Make more of his own - was able to explain his with normal
decisions behavior towards the researcher reference as the
Develop a sense of right and -was able to defend himself if he child was able to
wrong thinks he was wrongfully express his stand
Understand the effects of his accused on different
behavior -was able to explain why he was situation.
always with his peers

PSYCHOMOTOR Better able to move their The child was very active even Normal Data observed is
bodies with greater skill and before pandemic as he usually Development in accordance
precision. Gross and Fine plays basketball with his friends with normal
Motor skills improve as their past time. Child doesn’t reference as the
continously during participate in school activities participant was
adolescence. Adolescents can and sometimes skip classes. able to do
do more complex and recreational
strenuous activities compare to activities with his
when they were in their middle friends and do
school. The motor skills of household chores.
adolescent boys continue to
improve, particularly gross
motor skills. They rapidly gain
physical speed, jumping
strength, throwing strength,
and endurance throughout the
entire period of adolescence,
even into their early 20's.
EMOTIONAL, Teens at this age search for -thinks that friends understand Normal Data observed is
SOCIAL, identity – a sense of who they him more than his family in accordance
SPIRITUAL NEEDS are. They want to be more in -spends less time with family with normal
control and more independent.
They may:
Think friends are more
important than family, Spend
less time with parents, Want to
argue more and talk less, Start
to date, Become more aware
of sexual orientation, feel
things deeply and can get sad
or depressed.
and always at his friend’s house reference as
-The participant is in the stage of participant who is
looking for his own identity as at adolescent
evidenced by “.. kung unsa poy stage are in search
mga batasan sakong amigo, mao for his autonomy
rapod to akoang masundog, and identity
wako kabalo og unsa jud ako confusion.
kinaiya..”
 CHAPTER IV

RESULTS AND FINDINGS

The chapter deals with the analysis and discussions of the study.

Impact of Peer pressure in forming the Self-Identity to the Growth and

Development of Adolescence

Upon the face to face interview of the 17-year old adolescent on Capitol Homes

Subdivision in September 2020, it is evident that the child is in the stage of confusion and

seeking for autonomy, as the way he responded to the question, there are always uncertainty

and gathered answers showed that the adolescent is being more dependent with peers than

family. At first, establishing rapport is challenging to the participant as the adolescent stated

that he is not good in expressing himself but later gained his confidence to participate. In terms

of cognitive development, results showed that the adolescent is in normal development as he

was able to answers the questions being asked and explain the situation logically. He was also

able to reflect on his activities and recognizes his wrong doings. In terms of psychomotor

development, there was no problem being observed as the participant is active and engaging on

recreational activities. Moreover, in terms of the child’s social development, it was found out

that the adolescence development is in normal reference as the participant seeks more comfort

with peers than his family. Though the participant displays behavior he adapted from them and

has limited time in interacting with his family and becomes stubborn if being disciplined by his

mother, it is normal for the adolescents to experience peer pressure as it is part of the

development in encountering identity crisis. As for other development areas of the child were

found within a normal reference.

Proposed Intervention
 Peer pressure among adolescents is a complicated area. Helping the child in developing

coping skills in this crisis is necessary for their adulthood. Teenagers may feel that they have

“grown up”, their brains are still developing and immaturity is normally present into their

judgment and decision making. Peer pressure may somehow lead adolescents into good

outcomes such as being active in athletics or avoiding risky behaviors, or bad outcomes which

includes negative behaviors such as substance abuse and skipping school.

Nursing Care Plan

Assessment Diagnoses Planning Intervention Evaluation

Subjective Situational Low After the 8-hour Independent: Goal met. Child
“.. kung unsa self-esteem r/t intervention, the was able to
poy mga batasan peer dependency nurse will: -Provide child an explain the
sakong amigo, in decision opportunity for importance of
mao rapod to making as -Identify feelings verbalization and self-worth.
akoang evidenced by and underlying discussion of his
masundog, wako evaluation of self dynamics for situation. Goal met. Child
kabalo og unsa as unable to deal negative perception (Establishing was able to
jud ako with of self. rapport and verbalize
kinaiya..” events, confusion  encouraging patient acceptance of self
about self, -Verbalize to express self about as evidenced by
Objective: purpose or acceptance of self his concerns is “mao jud ni
-thinks that direction in life as is and an necessary.) akong naila na
friends increased sense of ako og mao ni
understand him self-worth. - Spend time with akong gikalahian
more than his the client; set aside sa uban kay lahi
family enough time so that lahi ta tanan” as
-spends less the encounter is verbalized.
time with family calm and deliberate.
and always at his (Having enough Goal met. Child
friend’s house time for the client was able to
will allow client to understand the
build trust towards importance of
the nurse as nurse sharing his
shows interest concerns to his
towards her guardian.
concerns.)
Goal met. Child
-Discuss client’s was able to
behavior towards his understand that
peers and family in a decision making
nonjudgmental way. should rely solely
(Nurse must convey with himself with
to client that he is a guidance of
worthwhile person parent and not
worthy of respect. with peers.
Discussion of
concerns will allow
nurse to understand
situations and have
an insight to
problems.)

-Observe family
interactions and
their level of support
towards the child.
(Understanding the
level of family
support and
guidance to child
will allow nurses to
understand if child’s
action is associated
with the level of
guidance he has.)

-Explain to client
that seeking for
autonomy is normal
in adolescents but
guidance with parent
is needed to prevent
negative outcomes.
(Confrontation
helps the client
accept the reality of
the problems as they
exist.)

Support the patient

in his or her
attempts to secure
autonomy, reality,
positive self-esteem,
sense of capability,
and problem-solving.
(The client needs
continuous positive
feedback and
support to manage
behaviors to
promote self-
esteem.)
 -Educate the client to
participate in
different activities
anticipated to result
in healthy self-
esteem.
(The client needs to
explore options to
improve self-esteem
by substituting
negative behaviors
with positive
actions.)

Chapter V

IMPLICATION OF NURSING PRACTICE

In this chapter, there are lists of implications for nursing practice presented and

developed by the researcher.

PROVIDE GUIDANCE

Children who was at stage of adolescence are normal to seek autonomy towards their

family. In acquiring the needs to fulfill the development child, parents are responsible for

guiding their child in exploring new things and ensuring that while doing those things, child’s

holistic health are not at risk. Parents must guide child especially at this development as peer

influence may lead to use of substances if not guided properly.

IMPROVE PATIENT EDUCATION

Providing education to patient is vital as the nurse considers the patient’s behavior and

knowledge in understanding her health. Improving knowledge to the child will allow him to

focus on the areas that needs to be improved and in areas that could lead child into different

that may affect his development. Education empowers patient to improve their health status.

FAMILY INVOLVEMENT

Guidance of the family is an important role needed to children, as child doesn’t have the

full capacity to make decisions and may perceived things differently. Family involvement along

with the healthcare provider will make the planned interventions for the child effective as

encouragements coming from the child’s trusted family members would be a good contribution

in improving his development.

CHAPTER VI

CONCLUDING REMARKS

In this chapter it offers the conclusion of the study and the recommendation in

accordance to the said study.

RECOMMENDATIONS

Identity confusion affects adolescents to be more vulnerable to peer pressure since they

may be desperate to find someone who may support them and can eventually end up peers to

control their lives. Peer pressure is common seen on people who have not yet developed a stable

personality thus the weaker the personality, the higher the chance to be involved with peer

pressure. We recommend that:

- Encouraging your child to talk about peer pressure and setting guidelines to deal with

peer pressure.

- Parents must establish limits, guidelines, and expectations and enforcing them with

appropriate penalties.

- Parents or guardian must present good modeling behavior towards their child.

- Complimenting your child is necessary for every personal achievements or cooperation.

- Parents must help their child to choose activities that are suitable for his or her abilities

or they found interesting.

- Parents must encourage child to spend time talking with you and be open with his or her

feelings.

- Parents must encourage child to get involved with hobbies and other activities.

- Parents must encourage child to engage in physical activities.

- Parents must build set of rules to follow and encourage self-discipline.

- Teaching your child to respect and listen to authority figures.

 LETTER OF INFORMED CONSENT

Praised be Jesus and Mary! Now and forever.

I, Anna V. Larita, second year student of St. Mary’s College of Tagum Inc. would like to
inform you of your participation in this case study in partial fulfillment of my requirement for
Related Learning Experience (RLE 107) in Maternal and Child Health Nursing.

 
 This study in growth and development of school age and adolescence contains different
health considerations and possible problems that could be possibly present within the
participant. This study is completely voluntary and the researcher will fully respect your
decision regarding the participation of this study. You are given enough time to organize your
thoughts and discuss with your parents or legal guardian. The details and information are
presented below for further understanding.

On the off chance that you and your guardian willingly volunteer to participate on
this case study, this procedure will happen:
 You will be interviewed by the researcher and you will be asked questions for
the information gathering.
 The whole interview process wil be recorded through video tapping and the
participant can choose whether to be seen within the process as long that the
voice or information are clearly conveyed.
 The researcher may conduct some assessments to assess your development.
 Interviewing phase will take 15-30 minutes long.

We don’t know how this study might benefit the participant but we hope that we
will learn something from assessing the existing concerns and problems of participant
that will help children with the same background in the future.

You may feel uneasiness over the span of the meeting on account of the delicate idea
of the point being asked. You are free not to answer questions which influence you to
feel any mental or enthusiastic pain or you can pull back as a participant of the study in
the event you feel that you can’t talk about the data that is asked to you.

The confidentiality of all the information from the data you have given will stay
private as far allowed by law. Any identifiable data acquired regarding this
investigation will stay private; anticipate that its importance will ensure your rights
or welfare.
I have read this form or someone has read it to me. If I did not understand
something, I asked the researcher to explain it to me. I can always ask the
researcher a question about the study if I don’t understand something. I will be
given a copy of this form.
Please check one box:

 YES, I want to be in this study and I know I can change my mind later.
 NO, I do not want to be in this study.
Child’s Name
(print legal name): John Mark V. Larita
 Child’s
Signature:

Date of signature: September 21, 2020 Age # 17

The research study and consent form was explained to:

Teresa V. Larita________
Person providing consent Relation to subject:
 Parent Legal Guardian
√

 The person who provided consent in film that all of their questions had been
answered and I agreed to their child's participation in this research study

 You confirm that they are legally authorized consent to the child's participation
 They agreed to let the research participant to use and share their child's health
 information

Anna V. Larita
______________________________
_______________________________________
Person obtaining consent Signature of person obtaining
consent

September 21, 2020

Date

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