All compassion centres operate within a grey area of the law, but have been deemed necessary by the Supreme Court of Canada.

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1 Membership Application Page 1: General Information Sheet Upper Canada Cannabis Company (UCC) is a compassionate medical cannabis organization. We provide the community with information relating to therapeutic use of cannabis, and facilitate member s access to a safe, consistent, dependable source of medicinal cannabis based products. Cannabis has been used effectively for thousands of years for the treatment of various medical conditions. In recent years, research has confirmed that cannabis in one of the best treatments available to help reduce the symptoms of numerous ailments. Furthermore, cannabis has been shown to be one of the safest therapeutically active substances known to mankind. Unlike most alternatives, cannabis has practically no harmful side effects and produces no significant physical dependence. Upper Canada Cannabis Company exists to prevent people from suffering unnecessarily. UCC and centres like it are necessary to fill the gap between our society s widespread acceptance of the benefits of cannabis and our government s reluctance to provide that which thousands of Canadians need: a reasonable source. All compassion centres operate within a grey area of the law, but have been deemed necessary by the Supreme Court of Canada. UCC membership is free, however it is restricted to people who meet our strict requirements. Please see page 2 for the three categories in which UCC accepts new members. We respect and protect the privacy and security of our members and their physicians. Thank You, Upper Canada Cannabis Company (UCC) Page 1 of 9

2 Membership Application Page 2: Application Procedure and Categories of Membership While we strive to make the membership process as quick and trouble-free as possible under the circumstances, approval can take time, and your patience is appreciated. Upper Canada Cannabis has 3 categories of membership. You only need to apply under one category. Category 1: People who are suffering from AIDS/HIV, Arthritis, Cancer, Crohns/Colitis, Epilepsy, Fibromyalgia, Glaucoma, Hepatitis C, Multiple Sclerosis, Muscular Dystrophy, Paraplegia/Quadriplegia, Chronic Pain, ADHD, Asthma, Brain/Head Injury, Cerebral Palsy, Chemotherapy Treatment, Depression, Eating Disorders, Eczema, Emphysema, End of Life/Palliative Care, Irritable Bowel Syndrome, Chronic Migraines, Nausea-Chronic, Debilitating, Neuralgia, Psoriasis, Parkinson s Disease, Radiation Therapy, Seizure Disorders, Sleep Disorders, Spinal Cord Injury. Category 1 applicants need to complete pages 3, 6, 7 and 8 of this membership package. Applicants must submit a Doctor s Letter of Diagnosis (page3). Applicants must also provide UCC with a copy of the Release of Confidential Medical Information (page 6), allowing UCC to confirm the diagnosis with the doctor s office. All applicants are required to submit a completed Personal Information Form (page 7), and Personal Experience Questionnaire (page 8). Optional: Letter of Intent Regarding Grower/Supplier Designation (page 9), Release of Confidential Medical Information Centre to Centre (page 5). *Note: Only a confirmation of diagnosis is required for category 1 applicants. Category 2: People who suffer from an ailment not covered by Category 1, and for whom a doctor feels that cannabis could be beneficial. Category 2 applicants need to complete pages 4, 6, 7 and 8 of this membership package. Applicants must submit a Doctor s Letter of Diagnosis and Endorsement (page 4). Applicants must also provide UCC with a copy of the Release of Confidential Medical Information (page 6), allowing UCC to confirm the diagnosis with the doctor s office. All applicants are required to submit a completed Personal Information Form (page 7), and Personal Experience Questionnaire (page 8). Optional: Letter of Intent Regarding Grower/Supplier Designation (page 9), Release of Confidential Medical Information Centre to Centre (page 5). Category 3: People who have received their government issued exemption. (Health Canada) Category 3 applicants need to complete pages 6, 7 and 8 of this membership package. Applicants must submit a clear, readable photocopy or scan of their current, valid MMAR Authorization to Possess Medical Marihuana license. (the pink paper) All applicants are required to submit a completed Personal Information Form (page 7), and Personal Experience Questionnaire (page 8). Applicants must also provide UCC with a copy of the Release of Confidential Medical Information (page 6) allowing UCC to confirm ATP with the signing doctor s office Optional: Letter of Intent Regarding Grower/Supplier Designation (page 9), Release of Confidential Medical Information Centre to Centre (page 5). * Note: We do verify all MMAR documents with the signing physician. After review and verification of the application, each new member will be contacted to book an orientation to introduce them to UCC s policies and procedures. A Code of Conduct will be provided to all new members, and all members must agree, in writing, to the conditions. Please be advised that all documents provided to UCC become the property of UCC and will be stored as securely as possible. Please make any desired copies of documents submitted to UCC prior to submitting them to UCC as we are not able to provide you with a copy of these documents for future use. Page 2 of 9

3 Membership Application Page 3: Doctor s Letter of Diagnosis for Category 1 Category 1 applicants must have their doctor complete the letter provided below, or provide a similarly worded letter with the same information on the doctor s own letterhead. This doctor s letter of diagnosis must be currentolder than 6 months will not be accepted. Dear Physician/Specialist/Naturopath: UCC is a resource centre the was established for the benefit of people suffering from conditions such as AIDS/HIV, Arthritis, Cancer, Crohns/Colitis, Epilepsy, Fibromyalgia, Glaucoma, Hepatitis C, Multiple Sclerosis, Muscular Dystrophy, Paraplegia/Quadriplegia, Chronic Pain, ADHD, Asthma, Brain/Head Injury, Cerebral Palsy, Chemotherapy Treatment, Depression, Eating Disorders, Eczema, Emphysema, End of Life/Palliative Care, Irritable Bowel Syndrome, Chronic Migraines, Nausea-Chronic, Debilitating, Neuralgia, Psoriasis, Parkinson s Disease, Radiation Therapy, Seizure Disorders, Sleep Disorders, Spinal Cord Injury, etc. Your patient is requesting a letter of diagnosis from you on our behalf. The purpose of the letter is to document for our records that this person has been diagnosed with one of the above-mentioned ailments. If you could please fill in the following statement and stamp this page or draft a letter (on your letterhead) based on the information provided below. Please keep a copy of your letter and the accompanying Release of Confidential Medical Information in your patient s file, as someone from UCC will contact your office to verify and validity of the letter. Date: / / (DD/MM/YYYY) This Letter is to certify that (patient s name), whom I have been treating since / (MM,YYYY), has been diagnosed with: (Please be specific). I am a licensed Medical Doctor / Naturopathic Doctor (circle one) permitted to practice in the province of, Canada. Stamp: (Doctor s original signature) Doctor s Name: CPSO/Registration # Office Phone # Office Office Fax # Page 3 of 9

4 Membership Application Page 4: Doctor s Letter of Endorsement for Category 2 Category 2 applicants must have their doctor complete the letter provided below, or provide a similarly worded letter with the same information on the doctor s own letterhead. This doctor s letter of diagnosis must be currentolder than 6 months will not be accepted. Dear Physician/Specialist/Naturopath: Category 2 is for people who suffer from an ailment not covered by Category 1, and for whom a doctor feels that cannabis could be beneficial. Your patient is requesting a letter of diagnosis from you on our behalf. The purpose of the letter is to document for our records that this person has been diagnosed with a serious chronic ailment and that their doctor feels that cannabis may have therapeutic value for them. You are not required to make any statements regarding dosage or safety of medical cannabis. Please fill in the following statement and stamp, or write a letter (on your letterhead) based on the information below. Please keep a copy of your letter and the accompanying Release of Confidential Medical Information in your patient s file, as someone from UCC will contact your office to verify and validity of the letter. Date: / / (DD/MM/YYYY) This letter is to certify that (patient s name), whom I have been treating since / (MM/YYYY) has been diagnosed with: (Please be specific), and that I, as their doctor, feel that cannabis may be beneficial to them. I am a licensed Medical Doctor / Naturopathic Doctor (circle one) permitted to practice in the province of, Canada. Stamp: (Doctor s original signature) Doctor s name: CPSO/Registration # Office Phone # Office Office Fax # Page 4 of 9

5 Membership Application Page 5: Release of Confidential Medical Information Centre to Centre For most UCC members, this release will never be used. If, however, there s a chance you may be moving (or travelling) to another Canadian city in which a reliable compassion centre/club does exist, this allows us to expedite your access to an alternative location to obtain cannabis medicine. UCC does not reveal any of your confidential information unless specifically requested to do so by you. I, (applicant s name) hereby request that my Check all that may apply: [ ] Confirmation of membership [ ] Confirmation of diagnosis [ ] Membership Application, Doctor s Letter(s) and other related details are to be released from UCC when requested by another compassion center/club or related organization ONLY for the purpose of facilitating my access to cannabis medicine when UCC believes I am trying to visit another centre/club. Applicant s Signature: Date: / / (DD/MM/YYYY) *Note: This form does not automatically guarantee membership at other centres/clubs. Page 5 of 9

6 Membership Application Page 6: Release of Confidential Information We require the applicant to provide UCC with a completed copy of this Release of Confidential Information. This form is to be filled out by the applicant and submitted with their application. Date: / / (DD/MM/YYYY) I, (patients name),do hereby grant permission for the release of my confidential medical information to Upper Canada Cannabis Company. I give permission for the doctor noted below to verify my medical status with a staff member of Upper Canada Cannabis Company by telephone or fax. Upper Canada Cannabis Company agrees to use this information for the sole purpose of confirming the authenticity of medical documents, and agree to keep this information strictly private and confidential. Patient s Signature: Referring Doctor s Name: (print) Doctor s Phone # Doctor s Doctor s fax # Page 6 of 9

7 Membership Application Package Page 7: Membership Form Please print clearly. First Name: Last Name: Date of Birth: / / (DD/MM/YYYY) Male / Female (circle one) Street Address: Mailing Address (if different): City: Province: Postal Code: Telephone # (home): (cell): (other): Emergency Contact Name: Relationship: Emergency Contact Phone Number: Doctor s Name: Doctor s Phone # Doctor s Address: I was referred to UCC by: (Member # ) Current medical diagnosis: Allergies: UCC STAFF USE Member # Category: Dosage: Date Confirmed: Doctor s Contact: H.C. E.C. O.I.C MMAR# Exp: Max: Page 7 of 9

8 Membership Application Page 8: Personal Experience Questionnaire Please tell us about your previous experience with cannabis: [ ] Currently use on a regular basis, familiar with various strains and methods of ingestion [ ] Tried it a few times recently [ ] Not since I was a kid [ ] Never tried it, but have done research [ ] Have no previous knowledge Comments: Every person reacts differently to cannabis, and even to individual strains. Be an informed patient by researching your medicine. If you do not have internet access, you can always use your local library. Page 8 of 9

9 Letter of Intent Regarding Grower/Supplier Designation Please not that this letter in an optional addendum to UCC s Membership Application Package. We ask that new members please fill out this letter, which we hope will never be needed in any way, but could possibly help the staff and directors of the centre in the unlikely case of legal proceedings against us. Since UCC s provision of medicinal cannabis products is yet to be authorized by our government, this letter is more about intentions and sprit than any actual agreement, and is in no way binding. Your signing of this letter does not obligate you to anything, in any way. Our hope is that someday an agreement like this one might actually be legal and might actually form the first step in a totally legal and legitimized patient-supplier relationship. If/when that day comes, we hope you will be eager to solidify a mutually beneficial arrangement as you, and UCC, then deem appropriate. THIS AGREEMENT made the day of, in the year BETWEEN: Upper Canada Cannabis Company (UCC) Hereinafter referred as UCC AND: UCC Member/Applicant know as Hereinafter referred to as Member Whereas the undersigned Member either A) possesses a Health Canada MMAR Authorization To Possess Medical Marihuana, or B) possesses another form of Canadian government issued exemption from Canadian laws against the possession and/or use and/or acquisition and/or cultivation of medicinal cannabis, or C) has applied for any such exemption, or D) may apply for any such exemption, or E) is not necessarily applying for any such exemption for whatever reason but is (or intends to become) a member in good standing with UCC with verification of a diagnosed ailment as per UCC s membership requirements; Therefore, Member hereby certifies their desire and intent to designate UCC as their primary grower/supplier of medicinal cannabis. Member: I,, of the province of hereby certify my intent to Designate UCC as my primary grower/supplier as outlined in this agreement. Member s Signature Page 9 of 9