Designation of Primary Caregiver

Primary Caregiver Form

Designation of Primary Caregiver
As per California Health and Safety Code §11362.5
I hereby certify that I am a patient suffering from serious illness and have obtained a
recommendation or approval from a licensed physician in the state of California to use medical cannabis
(marijuana) in treating my illness. A copy of my recommendation may be attached hereto.
I hereby designate the individual described below as my Primary Caregiver, in accordance with
California Health and Safety Code §11362.5(d) and §11362.5(e), which reads as follows:
(d) Section 11357, relating to the possession of marijuana, and Section 11358,
relating to the cultivation of marijuana, shall not apply to a patient, or to the patient s
primary caregiver, who posses or cultivates marijuana for the personal medical
purposes of the patient upon the written or oral recommendation or approval of a
physician.
(e) For the purposes of this Section, primary caregiver means the individual
designated by the person exempt under this act who has consistently assumed
responsibility for the housing, health, or safety of that person.
I agree that I will consistently rely on the individual described below as the primary source of
medical cannabis as a matter of my personal health and safety. This designation shall remain in effect (1)
for one year from the date below, (2) until I revoke this designation, or (3) until I designate another
individual as my primary caregiver.
Dated: ____________________
____________________________________ ___________________________________
Patient Name (print clearly) Primary Caregiver Name (print clearly)
___________________________________ ___________________________________
Patient Signature Primary Caregiver Signature
NOTICE TO LAW ENFORCEMENT: Pursuant to the Constitution of the State of California,
Amendment III, Section 3.5(c), state enforcement officials have no power to refuse to enforce
a statute on the basis that federal law or federal regulations prohibit the enforcement of such
statute. It is therefore your legal duty and responsibility to respect and obey this agreement per
the above cited legislation, and to leave the individuals herein described unmolested and
unreported to federal authorities. Failure to follow state law may result in legal action being
taken against you. Thank you for your understanding and compliance.