ONAC KM Sanctuary Garden Patient Member Application
(PLEASE answer All the questions below as Complete and accurately as is possible)
**Full Name: __________________________ ____________________________ ___________________________________________
**Date of Birth: ____ / ____ / ________
**Street Address: ____________________________________________________________________
City, State & Zip Code: ____________________________, ______________________, ____________ - _______
**Mailing Address (If Different): ______________________________________________________________
City, State & Zip Code: ____________________________, ______________________, ____________ - _______
**Phone Number(s): (Home); (____) - ______ - ________ ; Cell: (____) - ______ - _______ ; Message: (____) - _____ - ________
**Email: ____________________________@_______________
**State Medical Sanction #: ___________________ ; Issued: _____ / _____ / _______ ; EXPIRES: _____ / _____ / ________
**Primary Medical Conditions for which our sacrament is used:
1. ___________________________________________________________ ; Date of Onset: ___ / ____ / ______
2. ___________________________________________________________ ; Date of Onset: ___ / ____ / ______
3. ___________________________________________________________ ; Date of Onset: ___ / ____ / ______
**Are You a Military Veteran? { } Yes ; { } No ;
A. If YES, did you serve Active Combat? { } Yes ; { } No ; In: ________________________________________________________
B. If YES, which Branch(es) of Service did you serve? : ____________________________________________________________
C. If YES, What was your M.O.S.?: _______________________________ ; In where?: ______________________________________
By submitting this application to ONAC KM of Oregon, whether hard copy or electronically, you attest that ALL of the above information is true and correct to the best of your knowledge as of the date signed / submitted, and that you agree to the terms of the ONAC KM Patient Members Cultivation Agreement which MUST be signed and submitted PRIOR TO consideration of your acceptance or denial, and that you the applicant understand and accept that lack thereof could in result in the denial of your application.
Furthermore, upon the approval of your application by ONAC KM as well as your allowance of participation within the Sacrament Garden, you understand that said acceptance is an OFFERED option, not an owed nor required / guarenteed one, and that the option CAN BE REVOKED if the Garden Conduct Agreement is breeched on YOUR PART at any time including during the actual grow season itself by the Sachem of ONAC KM.
You as the sanctioned applicant also hereby agree upon submitting this application, that it is YOUR RESPONSIBILITY to keep your sanction current as well as accurate at All Times, and, that if it Expires OR is Revoked by either the state OR your physician, that YOU WILL notify ONAC KM Immediately and IN WRITING so to avoid endangering ONAC KM and the participating Patient Members within the sacrament garden, and that if you Fail to do so, and the church and or gardners face any LEGAL consequences because of your lack of disclosure, that You COULD be subject to civil and or criminal action and consequence as well as be Banned from consideration of participation in ANY ONAC Sacrament garden in ADDITION to any additional disclipinary action deemed appropriate by ONAC and/or ONAC KM.
Signature of Applicant: _____________________________________________________ Date: _____________________________
For church use only below
Interviewed By: __________________________________ Title: _________________ Date of interview: _________________________
{ } Approved ; { } Denied ; { } Pending
Assigned to Sanctuary Garden: ___________________________________
To Grower: ________________________________ (And Apprentice): ________________________________________ Date: ______________