Checked MindBody for existing member profile. State ID verified: Name matches recommendation and patient is age eligible.

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1 v4.7 Please complete this form. Print clearly using blue or black ink. Answer as accurately as possible. Assistance is available on request. 1. Identification Intake Form First Name Middle Initial Last Name Date of Birth City Zip Code Phone Sex How did you hear about SPARC? Are you a veteran? YES NO 2. Your Consent Are you a senior (62 or older)? Do you have a Caregiver? YES To the best of my knowledge, the foregoing information is correct. I authorize the San Francisco Patient and Resource Center (SPARC) to verify the information above. I authorize SPARC or its agents to contact me at any phone number I provide at anytime (including cellular / wireless telephone services), via a live operator, auto-dialer or prerecorded message. YES NO NO Patient Signature DO NOT WRITE BELOW. Space reserved for SPARC Staff only. Date Please Continue Checked MindBody for existing member profile. State ID verified: Name matches recommendation and patient is age eligible. Verified Dr. recommendation. Scan ID, Dr. recommendation, and SPARC member card: Name file. Verified all highlighted areas complete. Create member profile. Notes and client types updated Document uploaded. Membership activated Sign-in member for visit. Audited by. Exp. Date Dr. Last Name SPARC Member # 1256

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3 San Francisco Patient and Resource Center (SPARC) Health/Services Questionnaire As a nonprofit, SPARC aims to be the national model for patient services and health support among medical cannabis patients. We need your help to do that. Let us know how we can support you by filling out this form. All results will be submitted anonymously. v 1.8 A) What type of medical cannabis has most met your needs? INDICA SATIVA HYBRID CBD NOT SURE B) What is your preferred method of using medical cannabis? (Circle all that apply) SMOKING VAPORIZING EATING TINCTURES TOPICALS NOT SURE OTHER...Please list: C) Below is a listing of SPARC s current free services. Please rate each one according to your interest. In-House Acupuncture On Site Product Sampling Game Night Live Jazz Tea Bar D) In the next year, we will be offering more free healing services for members. What kinds of services would you find most helpful or be interested in? I. SERVICES: Art Therapy Self-Massage Reiki Legal Aid Clinic Ayurvedic Medicine (Food as Medicine) Meditation Please continue...

4 II. SUPPORTIVE/EDUCATIONAL GROUPS Medical Cannabis Education Chronic Illness/Pain Life Skills & Self-Management HIV/AIDS Group Hepatitis C Groups Co-Infection Groups Changing Habits Through Harm Reduction Cancer Groups Veteran s Groups E) Please rate the following on a scale from 1 to 10, with 1 being poor and 10 being "excellent" Your Energy Level: Your Quality of Sleep: Your Appetite & Digestion: Your Ability to Manage Pain: Your Mental Health: Your Overall Health: Thank you for your participation!

5 Please read carefully and sign below. v1.6 Assistance is available on request. SPARC Members Code of Conduct Be a Good Neighbor Members Code of Conduct SPARC believes that each member acts as an ambassador for our entire collective as well as the medical cannabis community. We strive to maintain a diverse collective membership and we do not discriminate based on race, gender, gender identity, sexual orientation, religion, income, or national origin. We want our patients to feel cared for, safe, secure, to be recognized as important members of our community, and to leave our facility inspired and empowered to be a positive voice for medical cannabis. SPARC is located in a dynamic area and we hope to be a positive influence in our community. SPARC developed this Code of Conduct to maintain a strong and positive relationship with our surrounding neighbors and neighborhood and to ensure that all members and employees are safe, secure, and are treated with respect, dignity, and compassion. Each SPARC collective member is required to comply fully and unequivocally with this Code of Conduct. SPARC reserves the right to terminate membership for any violation of the Code of Conduct. The Code of Conduct includes, but is not limited to, the following: Code of Conduct Reselling or otherwise distributing medicine obtained at SPARC to any individual IS STRICTLY FORBIDDEN. No double parking in front of the dispensary or in Laskie alley. Members in violation will be asked to move vehicles. Cannabis may not be consumed outside of the building within 500 feet of the exterior of the dispensary, including the entire Laskie alleyway. Members in violation will be issued a friendly reminder, but repeated and blatant violations will result in further action. Dabbing, smoking, or ingestion of medical cannabis requiring an open flame is NOT permitted inside the dispensary. Vaporization of cannabis or consumption of cannabis edibles is allowed in the vapor lounge area. Member visits at the vapor lounge are limited to 30 minutes. Tobacco products may NOT be vaporized or smoked inside the dispensary. Cellphone and electronic use IS permitted inside the dispensary for checking time, texting, personal music with headphones at a non-disruptive volume, calculator use, checking bank accounts, internet research, showing photos, game playing, etc. Taking photos, video and electronic recordings, disruptive music, and talking on cellphones IS NOT permitted inside the dispensary. Furthermore, any use of an electronic device deemed inappropriate IS NOT permitted. Laptops and tablets will be allowed to be used inside the dispensary. Video chatting (Skype, etc.), recording, broadcasting, watching explicit videos, and any other inappropriate use is NOT permitted. Members using laptops, tablets or other electronic devices are subject to the 30 minute time limit. We request that all members treat fellow members and staff with respect at all times. Offensive, abusive, threatening, hostile, or derogatory language will NOT be tolerated in the dispensary. For your safety, please place all medicine out of sight before exiting the dispensary. No removal of unauthorized or unpurchased SPARC property. Please no loitering or littering in front or alongside of our building including Laskie alley. No eating, sleeping, or any kind of soliciting is allowed inside the dispensary, except for beverages and consumption of cannabis edibles. By law, only qualified patients with a valid doctor s recommendation or state-issued ID card who become members of the SPARC collective may access the dispensary. Please do not bring non-patients or patients who do not have required documentation to the dispensary Members must ensure that they are in compliance with all applicable state and local limits for the possession and cultivation of medical cannabis. SPARC accepts no responsibility for any violations of applicable statues. All packages, bags, backpacks, purses, etc. brought into the dispensary are subject to search at any time. No alcohol, other controlled substances, or weapons are allowed inside the dispensary. SPARC is located in a dynamic area and we hope to be a positive force in our community. SPARC strives to maintain a strong and positive relationship with our surrounding neighbors, the City of San Francisco, and the Police department. As a member of SPARC s community, we ask that you be mindful of our neighbors property, privacy, and rights. Help us keep our commitments to our community by following our Code of Conduct and not creating an unnecessary nuisance. These simple precautions will help keep SPARC s neighbor and community relationships in good standing. Print Name Signature Date

6 Please read carefully and sign below. Assistance is available on request. San Francisco Patient and Resource Center (aka SPARC ) Collective Member Contract I. Purpose; Terms of Use a. This agreement delineates the terms, conditions and rules of membership in the San Francisco Patient and Resource Center (aka SPARC ) member collective. SPARC is a medical cannabis dispensary operating pursuant to a license issued by the City and County of San Francisco s Department of Public Health. v 3.5 Collective Member Contract b. SPARC membership is granted on an individual basis and operates subject to this agreement. Membership entitles patient or caregiver to access the SPARC dispensary and other member-service facilities during operating hours, subject to posted restrictions that may be amended from time to time. II. Eligibility for Membership a. To be eligible for membership in SPARC s patient collective, the Member must: i. Be a patient or primary caregiver, as defined by CA Health and Safety Code et seq; ii. Be at least 18 years of age at the time of application or be accompanied at all times by a parent or legal guardian; and, iii. Possess a valid physician s recommendation for medical cannabis or valid authorization to act as a primary caregiver for a patient in possession of a valid physician s recommendation. III. Disclosures a. Dispensing Collective: SPARC is a cultivation-collective (pursuant to CA Health & Safety Code , (e)) that facilitates the collaborative efforts of patient and caregiver members to cultivate and distribute medical cannabis. SPARC does not purchase marijuana from or sell to non-members, but merely provides a means for facilitating and coordinating transactions between members of the collective. SPARC operates as a California nonprofit mutual-benefit corporation, and the SPARC collective delegates authority for operation and management of the collective to the corporation s Board of Directors, who are elected pursuant to the corporation s bylaws. I acknowledge that SPARC is a cultivation collective under state law. I further acknowledge that, by joining SPARC, I authorize other members of SPARC to grow cannabis on my behalf at appropriate location(s) within the state of California. initial b. Proposition 65 Notice: In 2009, the CA Office of Environmental Health Hazard Assessment added marijuana smoke to its list of chemicals known to cause cancer. Member hereby acknowledges receipt of this notice. c. Not for Profit Operation - Charitable Giving Policy: In compliance with state and local law, SPARC operates not-for-profit and collects reimbursements from members for reasonable expenses associated with cultivating and distributing medical cannabis to SPARC patients. Further, SPARC is dedicated to helping our members and our community by providing subsidized services and other charitable contributions. SPARC reserves the right to levy a surcharge on transactions between members and the collective to fund these activities. By signing this contract, Member acknowledges and consents to contribute to these efforts. Member acknowledges that SPARC is not a tax-exempt organization under applicable state or federal revenue codes. IV. Member Code of Conduct a. By signing this agreement, Member acknowledges receipt and understanding of SPARC s Member Code of Conduct. Member further understands that violation of the Code of Conduct may result in immediate termination of membership in the SPARC collective or other remedies as appropriate. Member acknowledges that SPARC may, from time to time, amend and update this Code of Conduct. b. As stated in the Members Code of Conduct, reselling or otherwise distributing medication obtained at SPARC to any individuals is strictly forbidden. initial V. Informed Consent I acknowledge that SPARC makes no claims, of any sort, on behalf of any products, services, or treatment protocols for any condition whatsoever (despite overwhelming scientific evidence to the contrary). I understand that I should continue to seek professional medical consultation and monitoring while using any cannabis product. VI. Waiver; Indemnification a. Member Risk. In consideration of services rendered to me by SPARC, I agree, for myself and for my heirs, executors and assigns, to hold SPARC harmless from any loss, theft, cost, claim, injury, damage or liability ( Damages ) incurred as a result of the use of the SPARC facility or products provided by SPARC. I have been informed and acknowledge that SPARC makes no claims as to medical results that can be obtained through use of any SPARC products and has neither suggested nor will suggest any medical treatment to Members. I understand that cannabis remains a prohibited substance under Federal law and accept all risk associated with its possession and consumption. b. Loss of Property. Members are urged not to bring valuables onto the premises of a SPARC facility. SPARC shall not be liable for the disappearance, loss, theft, or damage to personal property, including money, negotiable securities or jewelry of Member. c. Acknowledgments. I received and agree to abide by the member handbook and Member code of conduct. I understand that my monetary contributions to SPARC, if any, are used to support the continued operation of SPARC and that this transaction in no way constitutes commercial promotion. I declare that I will not deliver any product obtained from SPARC to any other person not authorized by California law to possess them. VII. Amendments Member acknowledges that SPARC reserves the right to amend or update this agreement periodically and will provide proper notice to Member in the event of any change in terms. Any amendment initiated by the Member must be agreed to in a signed writing approved by a director or manager of the collective. VIII. Warning The facility at 1256 Mission Street in San Francisco contains chemicals known to the state of California to cause cancer and birth defects or other reproductive harm. Smoking cannabis-derived products will expose you and those in your immediate vicinity to marijuana smoke, a chemical known to the State of California to cause cancer. Signatures Member hereby acknowledges that s/he has read, understood and agreed to all terms and conditions of this agreement. (If member is under 18 years of age, parent or legal guardian must also sign the agreement.) SPARC Member Signature SPARC Member Printed Name Parent/Guardian Signature Date