June 26, 2017
New Patient Registration
New Patient Registration
Step 1 of 2 - New Patient Registration
Address Line 2
State / Province / Region
ZIP / Postal Code
Antigua and Barbuda
Bosnia and Herzegovina
Central African Republic
Congo, Democratic Republic of the
Congo, Republic of the
Northern Mariana Islands
Palestine, State of
Papua New Guinea
Saint Kitts and Nevis
Saint Vincent and the Grenadines
Sao Tome and Principe
Trinidad and Tobago
United Arab Emirates
Virgin Islands, British
Virgin Islands, U.S.
Date of Birth
Recommendation / Patient #
Recommendation Expiration Date
Physician's License #
DL/ID Expiration Date
I hereby state that as a qualified patient or a primary caregiver who has received a valid physician’s recommendation for the use of medical marijuana in accordance with the California Health and Safety Code § 11362.5 (“Proposition 215” or “Compassionate Use Act of 1996”) and Article 2.5, commencing with Section 11362.7, to Chapter 6 of Division 10 of the California Health and Safety Code (“SB 420”), wish to voluntarily join and become a member of BREH CA, (the “Collective”) and agree to follow the terms and conditions as set forth in this application and agreement.
1. I understand that the Collective is a nonprofit incorporated patient association formed in order to facilitate collaborative and cooperative efforts, including allocation of costs and reimbursements, for the exclusive and mutual benefit of its member patients and caregivers. I understand and agree that as a member I will be asked to contribute a comparable amount of money, property and/or labor as my equitable contribution for the collective cultivation of marijuana for the personal medical needs of all members. Further, I understand and agree that the quantity and the specific nature of the contributions from the individual members will be based on their individual preferences, talents, knowledge and/or skill and that some members will receive monetary reimbursements for their costs, expenses and labor involved in the assistance rendered to fellow members in cultivation, transportation or other tasks related to providing medical marijuana. I have been advised about the choice of types of equitable contributions I may choose to make to the Collective in exchange for medicine. I have also been advised of opportunities to take on a more participatory role in the Collective and/or to become more involved of the Collective’s finances and other types of decisions.
2. I hereby declare under the penalty of perjury under the laws of the State of California that a medical doctor recommended or approved my use of medical marijuana for an illness for which cannabis provides relief in accordance with the Compassionate Use Act of 1996 and SB 420.
3. As a member, I hereby appoint and designate the Collective and their representatives, as any true and lawful agents for the limited purpose of assisting me in obtaining my legally prescribed medical marijuana. I understand that this means that the Collective will be required to cultivate, possess, purchase, transport, distribute and/or, if necessary, purchase medical marijuana exclusively for member patients or primary caregivers. Therefore, I grant other fellow members the limited authority to engage in the afore-mentioned tasks, as required. I further agree and authorize the Collective and its members to use information relating to my status as a qualified patient as use of such information becomes reasonably necessary for providing my medical marijuana for my medical benefit as a qualified patient.
4. I authorize the Collective to create and/or assign agency rights in its own name for the purpose of growing marijuana for my personal medical reasons as well as for the medical benefit of other members of the Collective.
5. As a member, I understand that the Collective has other members who have joined and agreed to uphold the Collective’s rules and spirit by, among other things, signing a similar membership agreement. I hereby authorize the Collective to possess the medical marijuana as described under this agreement jointly with other members of the Collective under similar agreements. I agree that the medical marijuana possessed by the Collective is at any time the collective property of every patient who has joined the Collective, subject to the Collective’s rules and guidelines established by and for the Collective, for the purpose of handling medical marijuana for the exclusive benefit of member patients.
6. I agree to pay to the Collective all personal out-of-pocket expenses and reasonable compensation for services related to providing medical marijuana to me and other member patients.
7. I hereby verify that I am a resident of California and my personal medical marijuana will not be taken out of the State of California. I further verify and agree that medical marijuana shall not be shared, sold, bartered, traded, exchanged or delivered by any means to any other person for medical or other reasons. I understand that diversion of medical marijuana for non-medical purposes and/or to other individuals shall be grounds for the immediate termination of my membership. I also agree to request amounts of medicine strictly for my medical personal use at reasonably necessary intervals.
8. I agree to possess my original, or true and correct copy, of my physician’s recommendation, when I am on the property used by or belonging to the Collective. I understand that my failing to do so may result in the termination of membership and that verbal recommendations from physicians will not be accepted. I hereby agree to all future changes of the Collective’s policies as the laws relating to access to medical marijuana might change. I further agree to provide the Collective with all changes relating to my contact information as well as my status as a qualified patient.
9. I understand and agree that adherence to the rules of the Collective is the collective responsibility of all patient members, including myself. I agree that any violation of the terms of this Agreement or any other Collective member rules are grounds for the immediate termination of my membership.
10. I understand and agree that while medical cannabis has been authorized by both the people of the State of California and its legislature, and consistently upheld by all California courts, the Federal Government persists in enforcing portions of the Controlled Substances Act, which makes the possession and use of medical cannabis a federal crime. I hereby certify that I have been advised by an authorized agent of the Collective that possession and use of marijuana for medical purposes might be grounds for prosecution under federal law.
11. I have read over this entire Collective Membership Application and Agreement and certify that an authorized agent of the Collective has personally gone over and explained fully to me each paragraph of this agreement and that I have been provided a copy of this agreement.
I hereby affirm that I have read, understand and agree to the terms of the BREH CA Collective Membership Application and Agreement. Further, I declare under the penalty of perjury that the above is true and correct to the best of my knowledge.
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