Designation of Primary Caregiver

                       (California Health & Safety Code 11362.5)


I, _________________________________________________________,

                                     Print name legibly

hereby certify that I suffer from cancer, anorexia, AIDS, chronic pain, spasticity,

glaucoma, arthritis, migraine, or other serious illness and I have obtained a

recommendation or approval from a licensed physician to use medical marijuana (cannabis) in my treatment.                                                     

                        (A copy of my recommendation is attached).


I hereby designate ____________________________________________

                                       Print name legibly

as my “Primary Caregiver,” in accordance with Health & Safety Code 11362.5(d) and 11362.5(e),which read as follows:

(d) Section 11357, relating to the possession of marijuana, and Section 11358, relating to the cultivation of marijuana, shall not apply to a patient, or to a patients primary caregiver, who possesses or cultivates marijuana for the personal medical purposes of the patient upon the written or oral recommendation or approval of a physician.

(e) For the purpose of this section, “primary caregiver” means the

individual designated by the person exempted under this act who has consistently assumed responsibility for the housing, health, or safety of that person.

I agree that I will consistently rely on the above-named person as the

primary source of my medical marijuana as a matter of my personal health and safety.                                                                                         This designation shall remain in effect for a period of one year.

Dated: ______________________

Signature ______________________________________

                               NOTICE TO LAW ENFORCEMENT:

Pursuant to the Constitution of the State of California, Amendment III,

Sec. 3.5(c), state law enforcement officials have “no powerto refuse to enforce a statute on the basis that federal law or federal regulations prohibit the enforcement of such statute.”

It is therefore your legal duty and responsibility to respect and obey this agreement per the above-cited legislation, and to leave the individuals and gardens herein described unmolested and unreported to federal authorities. Failure to follow state law may result in legal action being taken against you.

                Thank you for your understanding and compliance

"A Union of the people for the people, created to fight sides with the people"                             (The sick, the ill and the strong will withstand to the end, unified and fearless)

                                                                                                      501(c)(3) non-profit corp.
 Corporate Office 6765 Westminster Blvd Suite C, Westminster CA 92683

Powered by Wild Apricot. Try our all-in-one platform for easy membership management