I ________________________ am applying to become a patient of The House of Mary Jane. I am aware that the HOMJ is a Medical Marihuana Dispensary authorized by the State of Michigan. I certify that I am a qualified patient under the rules and regulations established by the State of Michigan Medical Marihuana Program. I acknowledge the following:
- I am a legal resident of the State of Michigan.
- I am over the age of 18.
- I am and will continue to be in compliance with the State of Michigan Medical Marihuana Program. I acknowledge that obtaining medical marihuana from the HOMJ does not exempt a qualifying patient or caregiver from prosecution under Federal Law and the penalties provided by Federal Law.
- All medical marihuana obtained from the HOMJ is for my own personal use and that I may not distribute any medical marihuana to any person.
- I understand that it is illegal to transfer medical marihuana to any person, other than the transfer by my caregiver to a qualifying patient.
- The use of medical marihuana is strictly prohibited in and around the dispensary and its adjoining parking lot.
- Use of medical marihuana is not permitted in public places or on private property where it is prohibited.
- Operating a motor vehicle, aircraft or boat under the influence of Cannabis is prohibited under the law and can cause serious bodily injury and or death.
- I understand that I am not immune from imposition of any civil, criminal, or other penalties for smoking medical marihuana in a motor vehicle.
- I understand that I am not immune from the imposition of any civil, criminal, or other penalties for undertaking any task under than influence of medical marihuana, when doing so would constitute negligence or professional malpractice.
- I understand that am not immune from imposition of any civil, criminal, or other penalties for smoking medical marihuana or private property that is rented from landlord and is subject to a policy that prohibits the smoking of medical marihuana on the property.
- Medical marihuana is not FDA approved.
- There are potential adverse health risks that may accompany the use of medical marihuana. Scientific research has not established the safety of the use of medical cannabis by pregnant women.
- Cannabis should be stored in a safe place not accessible to children and all necessary steps MUST be taken to prevent children from obtaining or using medical marihuana.
- I agree to indemnify and hold the HOMJ harmless for any consequences resulting from use or purchasing of medical marihuana. I hereby acknowledge that the foregoing is true and correct.
Signature ____________________________________ Name ______________________________ Date ______________