CannaFreedom Sign Up

New Patient Sign-Up


MEMBERSHIP APPLICATION AND AGREEMENT FOR BEAM Brothers, Inc.

 A NON-PROFIT MUTUAL BENEFIT CORPORATION IN COMPLIANCE WITH HEALTH AND SAFETY CODE 11362.5 (Prop 215)

BEAM Brothers Inc., (“Collective”), a California Health and Safety Code 11362.5 compliant medical cannabis collective, and a non-profit, Mutual Benefit Corporation organized under Sections 12200, et seq., of the California Corporations Code (No. C3691480), facilitates the association of qualified medical patients for the purpose of cooperatively cultivating medical cannabis for its members, pursuant to Health and Safety Code sections 11362.765 and 11362.775. The Collective is dedicated to providing our members with the highest level, quality service pursuant to the Compassionate Use Act and Medical Marijuana Program Act (Health & Safety Code § 11362.5, et seq.). This agreement contains member requirements and guidelines to ensure compliance with the Compassionate Use Act, Medical Marijuana Program Act and the Attorney General’s Guidelines for the Security and Non-Diversion of Marijuana Grown for Medical Use; to protect the safety and further the health and well being of members; and to continue to create a member-run, community-based, alternative healing and wellness organization.

I hereby declare and agree as follows:

Article 1. I am a qualified patient entitled to the protection o f California Health and Safety Code section 11362.5, et seq., because my physician has recommended/approved my use of cannabis for medical purposes.

Article 2. My physician has determined that I suffer from a serious medical condition for which medical cannabis provides relief and has provided a written recommendation that verifies this fact. As a condition of membership, I have provided a copy of such recommendation to the Collective, as well as a copy of my current California Drivers License or other recognized form of state issued identification. I understand that the Collective will keep a copy of these documents on file and will independently verify with my physician my medical recommendation that forms the basis of my right to be considered a qualified patient under California law.

Article 3. In order to acquire the medicine my physician recommends, and in accordance with Health and Safety Code § 11362.5, et seq., I hereby seek membership in the Collective and understand that in order to be a member of the Collective, and to maintain my membership in the Collective, I must agree to, and follow all terms and conditions set forth in this agreement.

Article 4. I agree to provide the Collective with my current medical recommendation. I understand that I will provide a copy of my valid medical recommendation each and every time I visit the Collective to obtain my medical cannabis. I understand that any member whose medical recommendation is expired shall be excluded from membership until such time that their qualified status pursuant to the Compassionate Use Act can be verified.

Article 5. I understand that as a member of the Collective, I must contribute finances, labor and/or resources to the Collective. Such contributions are necessary to cultivate the medical cannabis to which I am entitled and need, as well as to conduct the day-to-day operations of the Collective for the mutual benefit of its members

Article 6. I have been informed and understand that there will be an annual meeting of all members of the Collective for purposes of voting as to the operation of the Collective and that I will be advised of the annual member meeting by U.S. Mail, email and/or Published notice posted at the Collective not less than ten (10) nor more than ninety (90) days before the date of the meeting. I understand that my attendance is very important in order to help make decisions necessary to the day-to-day operations of the Collective for the benefit of all members.

Article 7. I have been informed and understand that the Collective will make available to me upon reasonable request the complete Bylaws of the Collective, as well as records verifying the reimbursement necessary to compensate patient-members’ out-of-pocket expenses, time spent, and any and all operation and overhead expenses incurred in the course of cultivating and otherwise making available medical cannabis on behalf of the Collective.

Article 8. I agree to assign agency rights to the Collective for the limited purpose of obtaining legally cultivated medical cannabis and for purposes of growing medication for my benefit. I understand that the Collective is required to possess, transport, and cultivate medical cannabis on my and other members’ behalf, and limited authority is granted to the Collective for this purpose.

Article 9. I agree and understand that all medicine obtained is for medical use only and may not be diverted for non-medical use or for use by a non-member of the Collective. I understand that it is a violation of this agreement and of California law to sell or divert my medicine in any way and for any reason to any other person and a violation of this section will result in immediate revocation of my membership in the Collective. Also, to prevent diversion of marijuana to non-members, I understand that the Collective limits disbursement of medicine to each member to no more than two (2) ounces per week.

Article 10. I understand that as a member, I can possess an amount of cannabis consistent with my medical need. I understand that the Collective will require verification of my medical need by way of a specific Physician recommendation or through any means deemed acceptable to the Collective.

Article 11. I understand that my medical cannabis recommendation may be disclosed pursuant to any required audits by any Government agency for purposes of verifying the Collective’s compliance with the Compassionate Use Act, the Medical Marijuana Program Act, the Attorney General Guidelines, or any local ordinance. I understand that the Collective may maintain records of my medical use in order to demonstrate compliance with the Compassionate Use Act, the Medical Marijuana Program Act, the Attorney General Guidelines, or any local ordinance, and, further, that the Collective will take all legal steps necessary to keep such records private and confidential, subject to the need of the Collective to use such records to defend itself and establish that the conduct of the Collective and its members did not violate the law.

Article 12. As a member of the Collective, I recognize that there are risks inherent in the use of medical cannabis. All medical cannabis is obtained from members of the Collective at various locations not necessarily under the Collective’s direct supervision. While the Collective takes every reasonable precaution to assure the quality, purity and effectiveness of the medical cannabis, the Collective makes no warranties or representations as to the quality, purity and effectiveness of the medical cannabis. I understand that the Collective is not responsible for the effects and makes no representation or warranties, express or implied, with regard to the safety, effect or efficacy of the medical cannabis I may obtain from the Collective when used by itself or with other medicine.

Article 13. As a member of the Collective, I agree to follow the Bylaws and Rules and Policies of the Collective and I acknowledge I have been offered to review a copy of the Collective’s Bylaws and Rules and Policies.

Article 14. 1 hereby release, waive and discharge the Collective, including its officers, agents, employees, managers, independent contractors, parent organizations, subsidiaries, affiliates and other personnel (“Releasees”) from, and agree and covenant not to sue Releasees for, any claim, liability, or demand of any kind or on account of any personal injury, temporary or permanent disability, death, property damage, or other damages, whether caused by the negligence of Releasees or otherwise, resulting from or in any way associated with my presence on the premises Collective’s facilities, amenities, or services. Further, I agree and covenant to indemnify Releasees, for, and hold Releasees harmless, from such and claims, liabilities or demands.

I declare under penalty of perjury that the information provided on this membership agreement is true and correct. I further declare under penalty of perjury that I am a medical cannabis patient and will not divert my medicine for non-medical use or for use by a nonmember. I further declare under penalty of perjury that I am not a member of law enforcement and will not divert any medicine for the purpose of criminal investigations.

I have read and understand the above requirements and agree to follow these guidelines. I acknowledge that I have been offered the ability to review a copy of the Articles of Incorporation, Bylaws, and Membership Rules and Policies.

Additionally, I hereby authorize the release of my medical information concerning my diagnosis, condition or prognosis to the Collective and its authorized representatives for purposes of verifying the validity of my medical recommendation and the valid operation of the Collective pursuant to the Compassionate Use Act and Medical Marijuana Program Act.

CA ID:

Copy of Rec:

**NOTE** Wait for Upload above to complete before signing

Recommendation ID:  

Rec Verification Website:  

Your Phone Number:  

Your Address:

 

CannaFreedom Sign Up http://signup.cannafreedom.org
Signature Certificate
Document name: New Patient Sign-Up
Unique Document ID: dfeaf45090f4a32ce0e00be2e347656fbfa0666d
Timestamp Audit
2016-04-09 14:41:39 PDTNew Patient Sign-Up Uploaded by Joey Espinoza - tech@cannafreedom.org IP 73.92.131.120