Mmp for Cali

State of California—Health and Human Services Agency

California Department of Public Health

Medical Marijuana Program APPLICATION/RENEWAL

(Please Print)

For application instructions, view page 4.

This application is for: Patient Only (Applicant) SECTION 1

Name (last, first, middle initial)

Primary Caregiver Only TO BE COMPLETED BY ALL APPLICANTS.

Patient and Primary Caregiver

Mailing address (number, street)

Telephone number

(

City State ZIP code

)

County of residence

Additional contact information

Is applicant under 18 years of age?

Yes

No

If yes, complete Section 2 for the parent, legal guardian, or person with legal authority to make medical decisions for minor applicant, unless minor applicant is (check one): Lawfully emancipated; or SECTION 2 Declares self-sufficient minor status or is a minor capable of medical consent

TO BE COMPLETED FOR MINOR APPLICANT IDENTIFIED IN SECTION 1.

Telephone number if different from above

Parent/guardian/other name (last, first, middle initial)

(

Mailing address if different from above (number, street) City State

)

ZIP code

Relation to applicant (check one): Parent with legal authority to make medical decisions Legal Guardian Other person or entity with legal authority to make medical decisions SECTION 3 TO BE COMPLETED IF THE APPLICANT IS UNABLE TO MAKE HIS/HER OWN MEDICAL DECISIONS. Does the applicant have the capacity to make medical decisions? If “No,” enter the name and address of person acting on the applicant’s behalf:

Name (last, first, middle initial)

Yes

No

Telephone number

(

Mailing address (number, street) City State

)

ZIP code

Check one of the following to indicate the legal authority of the person (legal representative) signing this application on behalf of the applicant: I am the conservator for the applicant and I have authority to make medical decisions. I am an attorney-in-fact under a durable power of attorney for health...