Illinois Medical Cannabis Program Application For Registry Identification Card For Qualifying Patients Under 18 Years Of Age And Their Designated Caregivers Page 5
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7State of Illinois
Illinois Department of Public Health
Illinois Medical Cannabis Pilot Program
Application for Registry Identification Card for
Qualifying Patients Under 18 Years of Age and their Designated Caregivers
REVIEWING PHYSICIAN INFORMATION
Name of Hospital, University or Practice
First Name
Middle Name
Last Name
Office Address
Suite #
City
State
ZIP Code
Office Telephone Number (###-###-####)
E-mail Address
DESIGNATED CAREGIVER INFORMATION
The custodial parent or legal guardian shall serve as the designated caregiver and shall complete the
following information.
Drivers License # (if applicable):
Driver’s License State (if applicable):
First Name
Middle Name
Last Name
Home Address
Apartment or Suite #
City
State
ZIP Code
IL
Telephone Number (###-###-####)
E-mail Address
Date of Birth (mm/dd/yyyy)
Gender
Male
Female
_____________________________________________________________
____________________________
SIGNATURE of Designated Caregiver
DATE (mm/dd/yyyy)
Page 2 of 4
Printed by Authority of the State of Illinois
IOCI 15-164
P.O.#3115001
2M
12/14
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Parent category: Medical