Mid-Island Compassion Club
Box: 621
Phone: (250) 954-0363....E-mail: midislandcompassionclub@shaw.ca
Formally The
Coombs Club
Form 2
I, ______________________________________________--,
hereby appoint the Mid-island Compassion Club (M.I.C.C.) as my agent for the
purpose of procuring cannabis solely for my own personal use in the medical
treatment of ,
________________________________________________________
( medical condition )
This decision has been made of my own free will. I acknowledge that despite
overwhelming anecdotal evidence and limited studies to support the
effectiveness of cannabis as a medicine, the M.I.C.C. can make no guarantees or
medical claims. WAIVER AND INDEMNIFICATION CONSIDERATION OF THE SERVICES
RENDERED TO ME BY THE MID-ISLAND COMPASSION CLUB.
I hereby agree,
for myself and my heirs, executors and assigns, to waive any and all claims
against the
Mid-Island Compassion Club.
I declare that I will not deliver any product procured for me by the M.I.C.C.
to any other person. I affirm that I am 19 years of age or older, or have
written and verbal consent of my parent(s) / guardian(s) for membership in the
M.I.C.C.
I understand
that the M.I.C.C. operates under the doctrine of necessity as a defense to
conduct what the law would otherwise classify as criminal. B.C. provincial law, and federal law presently prohibit the use of medical
cannabis
by unauthorized patients.
I make all of the above statements truthfully
X____________________________________________________ Date:
_____________________
Signature
Printed: __________________________________________________
X___________________________________________________ Printed:____________________
Parent (s) / Guardian (s) Signature