Illinois Medical Cannabis Program Application For Registry Identification Card For Qualifying Patients Under 18 Years Of Age And Their Designated Caregivers Page 7
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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
Certifications (To be completed by the designated caregiver)
I certify the information provided in this application is true and accurate to the best of my knowledge.
Submission of false, misleading or inaccurate information in connection with this application is grounds
for revocation of the Illinois Medical Cannabis Qualifying Patient Registry Identification Card and other
administrative, civil or criminal penalties.
I additionally certify that I have been given actual Notice and understand that, notwithstanding the Compassionate
Use of Medical Cannabis Pilot Program Act (Act):
(i) cannabis is a prohibited Schedule I controlled substance under federal law;
(ii) participation in the program is permitted only to the extent provided by the strict requirements of the act;
(iii) any activity not sanctioned by the act may be a violation of state or federal law and could result in arrest,
conviction, or incarceration;
(iv) growing, distributing, or possessing cannabis under the act, unless done through a federally-approved
research program, is a violation of federal law;
(v) growing, distributing, or possessing cannabis in any capacity, except through a federally-approved
research program, may be a violation of state or federal law and could result in arrest, conviction or
incarceration;
(vi) use of medical cannabis, or possessing a medical cannabis patient or caregiver registry card, may
affect an individual’s ability to receive or retain federal or state licensure in other areas;
(vii) use of medical cannabis or possessing a medical cannabis patient or caregiver registry card, in tandem
with other conduct, may be a violation of state or federal law and could result in arrest, conviction or
incarceration;
(viii) participation in the Medical Cannabis Pilot Program does not authorize any person to violate federal
law or state law,
(ix) the act does not provide any immunity from or affirmative defense to arrest or prosecution under federal
law or state law, other than as set out in 410 ILCS 130/25; and
(x) applicants shall indemnify, hold harmless, and defend the state of Illinois for any and all civil or criminal
penalties resulting from participation in the program.
_____________________________________________________________
____________________________
DESIGNATED CAREGIVER SIGNATURE
DATE (mm/dd/yyyy)
This application must be submitted to:
Illinois Department of Public Health
Division of Medical Cannabis
535 West Jefferson Street
Springfield, Illinois 62761-0001
Page 4 of 4
Printed by Authority of the State of Illinois
IOCI 15-164
P.O.#3115001
2M
12/14
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