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I agree to provide a copy of the renewal of my physician's approval or recommendation on or before its expiration date.
I understand that the expiration of the physician's approval will result in the immediate termination of membership in Dank City Collective.
I understand Senate Bil 420 ("SB 420"), which created California state guidelines for Proposition 215 ("Prop 215"), reflects a compromise between patients' advocates and law enforcement and creates guidelines regarding how much marijuana patients may grow and possess without being subject to arrest.
Growing my own outside of Dank City Collective. I understand that if I grow my own medical marijuana, or my authorized caregiver grows lt for me, the production size is limited to six mature plants or twelve immature plants, or an amount necessary for my medical needs. Dank City Collective is not responsible for my personal cultivation of marijuana.
SB 420 also includes a voluntary patient identification card system and other provisions to protect patients and their caregivers from arrest. This program is understood to be referenced at item number 5 below.
I agree to follow SB 420's "restrictions on my marijuana use". I know and understand, I may not use marijuana any place where smoking is prohibited by law, which includes being within 1000 feet of a school, recreational center or youth center, unless use occurs within a residence; within 1000 feet of a school or youth center except in private residences, on school buses, in a motor vehicle that is being operated, or while operating a boat. I am aware of the protection that my local County Department of Public Health lD Card Program provides to the "Qualified Patient" or "Primary Caregiver" under its Medical Marijuana Program ('MMP"). I understand the Medical Marijuana ldentification Card ("MM|C") identifies the cardholder as a person protected under the provisions of Prop 215 and SB 420. lt is used to help law enforcement identify the cardholder as being able to legally possess certain amounts of medical marijuana under specific conditions. I understand obtaining this card from my local county health department is voluntary in California, and it is my responsibility to obtain a card and keep it on my person, if I wish to obtain one. I agree to complete a Dank City Collective member intake form which may be stored in a computerized Data Base. lncluded in these records may be my personal medical records as provided to the collective. ln addition, I understand that Dank City Collective will make every effort to store my medical information in a Health lnsurance Portability and Accountability Act ("HIPAA"; compliant manner to avoid disclosure of my personal health information from third parties. Notwithstanding the foregoing, I understand that Dank City Collective may encounter legal obligations impressed upon them requiring disclosure of my medical records and / or identity.
I am aware of my right to privacy of my health related information. I hereby authorize the use and disclosure of the medical information contained in the medical recommendation of my physician for medical marijuana, for confirmation with the doctor by the center, from time to time. I also understand a copy of my record will be kept by Dank City Collective ("Collective") on file and stored electronically. I understand that the Collective's policy on privacy is to not disclose the name or identity of any patient other than in the course of confirmation of the recommendation.
I understand that I may have extra protection under California and Federal law as to my information however I expressly authorize the use and storage of this information in accordance herewith. I understand I may revoke my authorization in writing at any time that the Collective will then maintain a record, but block out my name. I understand I am under no obligation to sign this form; however I realize that in order to ask the Collective to provide me access to medical marijuana, and at my own special request and instance, I grant the right to use the information as described herein. I understand I have a right to inspect or copy this authorization, and my file with the Collective. I understand that there is the possibility of re-disclosure of information in the course of confirming my recommendation. This authorization shall terminate on the termination of my medical recommendation unless terminated sooner in writing by me or my membership is terminated by the Collective pursuant to the bylaws. I have had an opportunity to review this form; I confirm it accurately reflects my wishes
I hereby acknowledge receipt of the HIPAA Notice of Privacy Waiver
I agree that the cannabis that I obtain from Dank City Collective, will be for my exclusive use and will not be distributed to any other individual.
I agree to follow Dank City Collective's policies and procedures as applicable to me as a member. I understand following policies and procedures are required as a condition of membership. Dank City Collective's policies and procedures are available for my review by appointment, if I should wish to review them. These policies and procedures may be required by law or the Collective, in addition to those which from time to time may be enacted or amended by the Board of Directors of Dank City Collective.
l agree to notify Dank City Collective in writing in the event that l wish to terminate my membership.
I agree to Dank City Collective's right to refuse service and/or terminate my membershlp based on disorderly conduct, rude behavior, or failure to follow Dank City Collective's policies and procedures.
I understand that I may have certain rights and as part of my membership with Dank City Collective, including having a right of advisory voting and rights of inspection of the bylaws and other corporate documentation as set forth in the bylaws.
I agree to hold Dank City Collective harmless should I violate any California or Federal law related to unlawful use, possession or sale of cannabis. Although Dank City Collective has provided me with limited legal information, regarding the laws of California related to cannabis, they have not provided me with legal advice. lf I need legal advice regarding my use or possession of marijuana, I should independently seek the advice of an attorney.