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DECLARATION OF PERSON RESPONSIBLE FOR A MINOR TO PARTICIPATE IN Oregon Medical Marijuana Program MAIL COMPLETED FORM TO DHS/OMMP PO BOX 14450 PORTLAND OREGON 97293-9929 Instructions Complete all required information in order to comply with the registration requirements of the Oregon Medical Marijuana Act. This form is required in addition to the patient application form if the patient is under 18 years of age. Please contact the DHS/OMMP if you need this material in an alternative format. I do hereby declare 1. That I am the Custodial Parent or Legal Guardian with responsibility for health care decisions for 1. decisions for Applicant s Name 2. The applicant s attending physician has explained to the applicant and to me the possible risks and benefits of the medical use of marijuana 3. I consent to the use of marijuana by the applicant for medical purposes 4. I agree to serve as the applicant s designated primary caregiver 5. I agree to control the acquisition of marijuana and the dosage and frequency of use by the applicant. SIGNATURE OF PERSON WITH PRIMARY CUSTODY ADDRESS TELEPHONE NUMBER CITY STATE AND ZIP CODE Subscribed to before me on this day of Notary Signature Seal/Stamp Notary Instructions If notary is using a raised seal indicate in which state you are registered as a notary and the date your commission expires. Notary signature and seal must appear on this form* Do not attach a separate notary statement. Ommapcust0102. This form is required in addition to the patient application form if the patient is under 18 years of age. Please contact the DHS/OMMP if you need this material in an alternative format. I do hereby declare 1. Please contact the DHS/OMMP if you need this material in an alternative format. I do hereby declare 1. That I am the Custodial Parent or Legal Guardian with responsibility for health care decisions for 1. That I am the Custodial Parent or Legal Guardian with responsibility for health care decisions for 1. decisions for Applicant s Name 2. The applicant s attending physician has explained to the applicant and to me the possible risks and benefits of the medical use of marijuana 3. decisions for Applicant s Name 2. The applicant s attending physician has explained to the applicant and to me the possible risks and benefits of the medical use of marijuana 3. I consent to the use of marijuana by the applicant for medical purposes 4. I agree to serve as the applicant s designated primary caregiver 5. I consent to the use of marijuana by the applicant for medical purposes 4. I agree to serve as the applicant s designated primary caregiver 5. I agree to control the acquisition of marijuana and the dosage and frequency of use by the applicant. I agree to control the acquisition of marijuana and the dosage and frequency of use by the applicant. SIGNATURE OF PERSON WITH PRIMARY CUSTODY ADDRESS TELEPHONE NUMBER CITY STATE AND ZIP CODE Subscribed to before me on this day of Notary Signature Seal/Stamp Notary Instructions If notary is using a raised seal indicate in which state you are registered as a notary and the date your commission expires.

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Keywords relevant to Ommp Minor Declaration Form

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