Medical Cannabis Caregiver Registration - Illinois Department
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4State of Illinois
Illinois Department of Public Health
Illinois Medical Cannabis Pilot Program
Application for a Designated Caregiver Registry Identification Card
INSTRUCTIONS
To qualify for a designated caregiver registry identification card, a designated caregiver must:
•
be a resident of the state of Illinois at the time of application and remain a resident during participation
in the program;
•
complete the fingerprint-based background check and not have been convicted of an excluded offense
(a violent crime as defined in Section 3 of the Rights of Crime Victims and Witnesses Act or a felony
under the Illinois Controlled Substances Act, Cannabis Control Act or Methamphetamine Control and
Community Protection Act, or similar provisions in a local ordinance or other jurisdiction), unless they
have an approved waiver for the excluded offense;
•
serve only one qualifying patient; and
•
be at least 21 years of age.
A complete application must include all of the following:
A signed and completed application form.
Qualifying patient information.
Proof of residency.
Proof of identity of the designated caregiver.
Proof of age of the designated caregiver.
Photograph of the designated caregiver (Contact the Department’s Division of Medical Cannabis if a
photograph would be in violation of or contradictory to the qualifying patient or designated caregiver’s
religious convictions).
Copy of the fingerprint consent form and the receipt provided by the livescan fingerprint vendor containing
the Transaction Control Number (TCN).
Excluded offense waiver, if applicable.
Application fee.
If mailing, this application must be submitted with the qualifying patient application to:
Illinois Department of Public Health
Division of Medical Cannabis
535 West Jefferson Street
Springfield, Illinois 62761-0001
Page 1 of 2
Printed by Authority of the State of Illinois
IOCI 15-164
P.O.#3115002
2M
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