As a qualified patient protected by California Law, Health and Safety Code 11362.5 & 11362.1 et seq., and in conjuction with California State Bill 420, you are required to read and agree to the following to become a member of On Deck Cooperative.

I consent to the benefits provided by the On Deck Cooperative, hereafter "the Cooperative", and agree to abide the bylaws, rules, and regulations of the Cooperative.

I agree, if accepted to join the Cooperative, that any medical marijuana provided by the Cooperative shall not be distributed to unqualified patients.

I am informed that membership in the Cooperative is a private membership organized under Chapter 1 of Division 20 of the California Food and Agricultural Code and that if accepted; my membership alone does not warrant legal use of Marijuana.

I was diagnosed with a "serious medical condition" that substantially limits my ability to conduct one or more major life activities for which the use of marijuana provides relief.

I have been informed & understand that acceptance of my application is at the discretion of the Cooperative. The Cooperative reserves the right to refuse my membership.

I acknowledge that my contributions are used to ensure continued operation of the Cooperative and are applied toward future harvests of the Cooperative's medicine.

I understand that as a qualified patient I have the California State Constitutional right to use medicinal marijuana if recommended by a licensed medical physicians in good standing.

Furthermore, I acknowledge and accept as true that medical marijuana is illegal under federal law and thereby membership and the submission of an application to join the Cooperative are acts inconsistent with federal law.

By Signing below, I hereby authorize my recommending physician to release information regarding my diagnosis and condition to the Cooperative.

I am either the Printed named above or the Patient's legally authorized representative. This release authority applies to any information governed by the Health Insurance Portability and Accountability Act of 1996 ("HIPAA"), 42 U.S.C. 1320d and 45 C.F.R 160-164, and/or information governed by the California Confidentiality of Medical Information Act ("CMIA") Cal. Civ. Code 56-56.37. Specifically, this release authority complies with the valid authorization requirements of 45 C.F.R. 164.508(c). Pursuant to HIPAA and/or CMIA, I authorize and direct any physician, healthcare professional, dentist, health plan, hospital, clinic, laboratory, pharmacy, or the covered health care provider, any insurance company, and the Medical Information Bureau, Inc., or healthcare clearinghouse that has provided treatment or services to me or that has paid for or is seeking payment from me such services, to give, disclose, and release, without restriction, all of my individually identifiable health information and medical records regarding any past, present, or future medical or mental health condition,to include all information relating to the diagnosis and treatment of sexually transmitted disease, mental illness, and drug or alcohol abuse to On Deck Cooperative. The purpose of the usage and disclosure shall include determinations regarding my qualifications to use medical marijuana and monitoring my health care to protect my legal rights where I reside. I understand that, with certain exceptions, I have the right to revoke this Authorization at any time. If I want to revoke this Authorization, I must do so in writing. The procedure for how I may revoke this Authorization, as well as the exceptions to my right to revoke will be performed in accordance with applicable federal law and any applicable policy of my health care provider. I understand I may refuse to sign this Authorization. I also understand that my health care provider cannot deny or refuse to provide treatment, payment, and enrollment in a health plan, or eligibility of benefits if I refuse to sign this Authorization. I understand that, once information is disclosed pursuant to this Authorization, it is possible that I will no longer be protected by applicable federal medical privacy law and could be re-disclosed by the person or agency that receives it: however, I do not authorize such secondary disclosure. The authority given to the persons or parties named above shall supersede any prior agreement that I may have made with my health care providers to restrict access to or disclosure of my individually identifiable health information. The authority given has no expiration date and shall expire only in the event that I revoke the authority in writing and deliver it to my healthcare provider. I have read and understand the information in this Authorization form.

As a member of On Deck Cooperative, herein "the Cooperative," you know that medical marijuana has been legalized for use only by qualified members and primary caregivers. The Cooperative relies on our members to cultivate and provide medical marijuana. However, as these laws are new and changing, our state government has not provided us regulations on the quality control or procedures for the cultivation of medical marijuana. In obtaining medical marijuana, we members of the Cooperative take care to provide you medicine free from all toxins. When we receive marijuana edibles or marijuana from members, we attempt to assure that these members bake and prepare edibles in kitchens approved by the Ventura County Public Health Department or cultivate marijuana organically. However, we cannot control the preparation of each edible nor monitor the cultivation of every plant. In consideration of receiving membership and participating in the Cooperative we ask that you hereby release, waive, discharge, and covenant not to sue the Cooperative, its officers, servants, agents, and employees (herein after referred to as releases" from any and all liability, claims, demands, actions, and causes of action whatsoever arising out of or relating to any loss, damage, or injury, including death, that may be sustained by you, whether caused by negligence of the release's or otherwise while a member of the Cooperative or while in, on, or upon the premises of the Cooperative. I am fully aware of risks and hazards connected with obtaining and using medical marijuana or edibles provided to me by the Cooperative, and I am fully aware that there may be risks and hazards unknown to me. I voluntarily assume full responsibility for any risks of loss personal injury, including death that may be sustained by me as a result of me being a member of the Cooperative. I further hereby agree to indemnify and save and hold harmless the releases and each of them, from any loss, liability, damage, or costs they may incur due to my participation in the cooperative, whether caused by the negligence of any or all of the releases or otherwise. Its is my express intent that this release Shall bind the members of my family and spouse if I am alive, and my heirs, assigns, and personal representatives if I am deceased, and shall be deemed as a Release, Waiver, Discharge, and Covenant not to sue the above named release's. In signing this Release, I acknowledge and represent that: I have read the forgoing release, understand it and sign it voluntarily as my own free act and deed. No oral representations, statements, or inducements, apart from the forgoing written agreement, have been made. I am at least eighteen (18) years of age and fully competent. I execute this Release for full, adequate, and complete consideration fully intended to be bound by the same.

Contact Us:

(661) 474-4632

ondeckcoop@gmail.com

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Copyright 2015 On Deck Cooperative