I_____________________________ (print name) as a qualified patient protected by California Law, Health & Safety Code §11362.5 and §11362.7, et seq., and, in conjunction with California State Senate Bill 420, you are required to read and agree to the following statements to become a member of Tree Kastle, Inc.. Please understand that these are for your protection, as well as ours. Please read the following statements and initial that you have read each where provided. Please sign the bottom of this form confirming that you read each of the statements and understand them. 1. I am legally able to use, possess, and cultivate cannabis for medical purposes. I understand that I am allowed to do so through safe and affordable access such as the type provided by Tree Kastle, Inc., therefore, designate Tree Kastle, Inc. as my care provider for this purpose. In doing so, I agree to sign and follow all Tree Kastle, Inc. rules and regulations regarding their services 2. I further authorize Tree Kastle, Inc. to create and/or assign agency rights in its own name for the purpose of growing medication and/or obtaining edible forms of medication for my benefit.
3. I also agree to pay all personal out-of-pocket expenses and reasonable compensation for Tree Kastle, Inc.’s member services.
4. I hereby declare under penalty of perjury under the laws of the State of California that a medical doctor recommended or approved my use of medical marijuana. I have been diagnosed for a serious illness for which cannabis provides relief. 5. I hereby verify that I am a California resident and my personal medical marijuana will not be taken out of the State of California. I further verify and agree that my medical marijuana shall not be shared, sold, bartered, traded, exchanged or delivered in any other means to any other person.
6. I hereby declare and understand that my contributions to Tree Kastle, Inc. for and through prescribed medicinal products I may acquire from Tree Kastle, Inc. are used to ensure the continued operation of Tree Kastle, Inc. and that any said transaction in no way constitutes a commercial promotion or sale of any item. 7. As a member, I hereby agree, appoint and designate Tree Kastle, Inc., and their representatives, as my true and lawful agents for the limited purpose of assisting me in obtaining my legally prescribed medicinal marijuana. I understand that this means Tree Kastle, Inc. will be required to purchase, possess, transport and distribute my medication to me as prescribed by my physician and I grant them the limited authority to do so. I further authorize Tree Kastle, Inc. to share their primary caregiver status of my person in order to enter into contracts to
obtain and/or allow growth/preparation of medication and edibles for my benefit. 8. As a member, I understand that Tree Kastle, Inc. has other members with similar Membership Agreements. I hereby authorize Tree Kastle, Inc. to jointly possess the medical marijuana as described under this Agreement jointly with other Tree Kastle, Inc. members under similar Membership Agreements. I agree the medicinal marijuana possessed by Tree Kastle, Inc. at any time is the collective property of every patient who is also under this Membership Agreement and the care of Tree Kastle, Inc.. 9. I agree to provide Tree Kastle, Inc. with all changes in my contact information, diagnosis, or primary physician immediately. I, hereby consent to the benefits provided by Tree Kastle, Inc.. I understand that the Tree Kastle, Inc. has made no efforts in encouraging me to produce or use any substances for my medical condition. I have been informed by an authorized representative of Tree Kastle, Inc. that I should continue to seek professional medical advice prior to and during my use of any cannabis product I may acquire through Tree Kastle, Inc..
I understand that the Tree Kastle, Inc. was organized to fill the necessity of medical cannabis. I further understand that circumstances may require defense of authorization in a court of law and agree to participate in such defense to the extent necessary and practicable. I understand that the Tree Kastle, Inc. reserves the right to refuse service(s) to members. I affirm that I am above eighteen (18) years of age or have the consent of my parent/guardian, and that I have a medical condition(s) as attested to on my information form.
DISCLAIMER - GENERAL RELEASE, INDEMNIFICATION AND HOLD HARMLESS CLAUSE Being of lawful age and sound mind, do now release, acquit, and forever discharge Tree Kastle, Inc. herein referred to as owner, of Tree Kastle, Inc. from all actions, claims, demands, or damages accruing to me from any known or unknown injury, loss, or damage sustained by or to me. This release shall remain in force and run concurrently with my membership in Tree Kastle, Inc.. In witness whereof, I have executed this release in California. I further agree to indemnify and hold harmless Tree Kastle, Inc. from any injuries or damages resulting from use or misuse of medical marijuana obtained from Tree Kastle, Inc..
I hereby affirm that I read, understand and agree to the terms of the Membership Agreement/Hold Harmless Agreement.
Patient’s Signature: ___________________________________ Date: _______________
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1547 Palos Verdes Mall #124
Walnut Creek, California