I, (member representative) certify that I am legally responsible person of (member) and I consent to the following for him/her for a period not to exceed 12 months from the date of my signature.
This has been explained to me and I certify that I fully understand. I also understand that my consent may be withdrawn at any time by my written notification.
I, (member representative) certify that I am the legal responsible person of (member) and I consent to the following for him/her for a period not to exceed 12 months from the date of my signature.
The preceding has been explained to me and I certify that I understand it fully. I also understand that my consent may be withdrawn at any time by my written notification.