Application Form For Registration Of Minor Patient Form - Michigan Department Of Community Health Page 5
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5Michigan Department of Community Health
DCH/MMP-040 (3/09)
Michigan Medical Marihuana Registry
P.O. Box 30083
Lansing, MI 48909
Declaration of Person Responsible for a Minor Applying to
Participate in the Michigan Medical Marihuana Registry
(Parent or Legal Guardian)
INSTRUCTIONS: Please complete all required information in order to comply with the requirements of the Michigan
Medical Marihuana Registry. This form is required in addition to the patient application form if the patient is under
18 years of age.
PLEASE TYPE OR PRINT LEGIBLY
DECLARATION: (REQUIRED)
I,
, do hereby declare:
______________________________________________________________________________
That I am the Parent/Legal Guardian (circle one) with responsibility for health care decisions for:
____________________________________________________________________________
Applicant’s Name
•
The applicant’s attending physician has explained to the applicant and to me the possible risks and
benefits of the medical use of marihuana.
•
I consent to the use of marihuana by the applicant for medical purposes.
•
I agree to serve as the applicant’s designated primary caregiver.
•
I agree to control the acquisition of marihuana and the dosage and frequency of use by the
applicant.
•
I have provided statements of certification regarding the patient’s status from two (2) licensed
physicians.
PARENT OR LEGAL GUARDIAN INFORMATION: (REQUIRED)
ADDRESS
TELEPHONE NUMBER
(
)
CITY
STATE
ZIP CODE
EMAIL ADDRESS
(Optional)
MI
RELATIONSHIP TO APPLICANT
SOCIAL SECURITY NUMBER OF PARENT OR LEGAL GUARDIAN
/
/
__________________________________________________________________________
_____________________
Parent’s or Legal Guardian’s Signature
Date
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