Member Registration Please fill out all areas of the form Member Name First Last Email VerificationPlease upload a copy/scan of the following documents:Please Provide Verification of Service (VA Card or DD-214)Valid California IDMedical Cannabis Doctor's RecommendationDr. NameDr. PhoneRec. NumberRec. Expiration DateMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920DL NumberDL Expiration DateMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920If you require assistance or have any questions please feel free to contact us at (831) 431-6347Membership AgreementAll applicants for collective membership shall read the following statements and, if in agreement, initial where indicatedA CALIFORNIA NOT FOR PROFIT COLLECTIVE OF MEDICAL MARIJUANA PATIENTS This “Not for Profit” Collective consists of qualified patients and primary caregivers who associate in order to lawfully and collectively cultivate, use and safely provide marijuana to each other for medicinal purposes. Patient members shall only be admitted to Collective membership after they have obtained a doctor’s recommendation or an identification card from the state Department of Public Health or their County department implementing the identification card program, AND after signing the following membership agreement stating they have read, understood and agreed to all Collective rules. Membership may continue only so long as their doctor’s recommendation or state card has not expired and all Collective rules are followed. Members of this collective shall include all patient members regardless of their method of contribution. Members include but are not limited to: the patient members who administer the collective’s work; the patient members who grow the medicinal marijuana for the collective’s medical use; the patient members who transport the medicinal marijuana for the collective’s medical use; and patients who contribute only money or goods to further the collectives lawful ends. All applicants for collective membership shall read the following statements and, if in agreement, initial where indicated: 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. Patient/Member Initials:*I hereby declare that I have read and understood the following California laws and guidelines: Health & Safety Code §11362.5 and §11362.7, et seq., the Department of Justice, State of California, Guidelines for the Security and Non-Diversion of Marijuana Grown for Medicinal Use issued August 2008, and Santa Cruz County’s Municipal Code guidelines for marijuana use and cultivation: Chapter 7.124 MEDICAL CANNABIS USER AND PRIMARY CAREGIVER IDENTIFICATION CARD; (OR) the City of Santa Cruz codes Chapter 6.90, et. seq. Patient/Member Initials:*I have been diagnosed for a serious illness for which cannabis provides relief. I am a qualified patient or caregiver under CA H&S Code §11362.5, §11362.7. As per CA H&S Code §11362.51, 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 SC VETERANS ALLIANCE Collective. In doing so, I agree to sign and follow all SC VETERANS ALLIANCE Collective rules and regulations regarding their services. I also agree to pay all personal out-of-pocket expenses and reasonable compensation for SC VETERANS ALLIANCE Collective’s member services. I agree not to use the medical cannabis for other than medical purposesPatient/Member Initials:*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. Patient/Member Initials:*I hereby declare and understand that my contributions to SC VETERANS ALLIANCE Collective for and through prescribed medicinal products I may acquire from SC VETERANS ALLIANCE Collective are used to ensure the continued operation of Collective and that any said transaction in no way constitutes a commercial promotion or sale of any item.Patient/Member Initials:*As a member, I hereby agree, appoint and designate SC VETERANS ALLIANCE Collective 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 SC VETERANS ALLIANCE Collective will be required to purchase from collective members, possess, transport and distribute my medication for me and I grant them the limited authority to do so.Patient/Member Initials:*I agree to possess my original, or a true and correct copy, of my recommendation when I am on SC VETERANS ALLIANCE Collective property. I understand that my failing to do so may result in refusal of services. I hereby agree to all future changes of these policies as the laws for safe access develop. I agree that any violation of the terms of this Agreement or any other collective rules are grounds for immediate termination of membership. Patient/Member Initials:*I agree to provide SC VETERANS ALLIANCE Collective with all changes in my contact information, diagnosis, or primary physician immediately.Patient/Member Initials:*SCVA Membership Introductory Information* I have read the SCVA rules and regulations found by clicking here By signing below, I hereby affirm that I read, understand and agree to the terms of the SC VETERANS ALLIANCE Collective Membership Agreement.*Please write out your full name in the box provided.
