Sign-Up for our Collective

Please fill out this short form below to join our collective. By filling this form out online, you streamline the process and we can pre-approve you with your doctor.

We will have a copy of your submitted form, for you to sign, on your first visit.

Thank you,
HashCentral Collective

Section 1 - General Information

First Name*
Middle Name
Last Name

Address

City
State
Zip Code

California Driver's License or ID No
Date of Birth

Tel No
Email*

Section 2 - CA DHS ID patients or Referring Doctor Information

Card No
Expiration Date

-- or --

Doctor's Name/Office
Doctor Office Phone

Patient Number/Code
Issue Date

Section 3 - Declaration

  1. I am a qualified patient or Primary Caregiver pursuant to the laws of the State of California with a current recommendation from a licensed physician.
  2. I certify under the penalty of perjury I am not a law enforcement official, officer or agent. I am not signing this agreement nor joining HashCentral Collective or purchasing medical cannabis for any law enforcement purpose.
  3. I have read, I understand and I agree to the HashCentral Collective Identification Card agreement and the HashCentral Collective and Regulations Agreeement and I consent to joining this collective pursuant to the terms set forth in these agreements.
  4. I certify under the penalty of perjury that the information provided on this agreement is true and accurate and that I am not seeking membership in HashCentral Collective for any fraudulent purpose.
  5. I will not distribute any medicine received from HashCentral Collective to any other person, and I shall use it for medical purposes only.
  6. I authorize my recommending physician to verify his or her recommendation, authorization or approval for my use of medical cannibis.
  7. I authorize and assign HashCentral Collective , on my behalf, to possess, and distribute to HashCentral Collective members who are qualified patients up to (8) eight ounces of medical cannabis and 6 cannabis plants afforded to me pursuant to Health and Saftey Code section 11362.5 et seq.

I have read the declaration points above and agree to follow them


Section 4 - Rules and Regulations Agreement

It is the policy of HashCentral Collective to update our rules and regulations from time to time to reflect changes in the law. It is your responsibility to keep an up to date recommendation. Our staff members are not expected to remind you or your expiration date. The following rules and regulations are strictly enforced at all times.

  1. It is understood by all parties that membership in HashCentral Collective is a privilege not a right. HashCentral Collective members must be 18 years of age or older.
  2. Membership may be revoked at anytime by management or the Board of Directors for violation of any action not covered by the rules and regulations that, in the opinion of the Board of Directors or the management, brings discredit, unwelcome public attention or unwanted burden to our collective.
  3. The facilities at HashCentral Collective are designed to provide a safe, friendly environment for our members. Members with disabilities understand and agree that their access and use of HashCentral Collective facilities shall be limited to places of public accommodation and other places to which the general public is invited only. Assistance to disabled members shall be offered upon request.
  4. There is no bathroom access for HashCentral Collective members or members of the public at any HashCentral Collective facility.
  5. Except for HashCentral Collective staff and management, the operation of cell phones, recording devices and cameras is prohibited in all HashCentral Collective facilities at all times.
  6. No person shall accept deliveries from HashCentral Collective or enter the private areas of HashCentral Collective facilities without a valid recommendation for medical cannabis, as well as a valid California State issued Identification Card or HashCentral Collective identification card.
  7. Loitering is not allowed at or in front of any HashCentral Collective facilities at any time.
  8. Dogs (other than guide dogs) are not allowed at HashCentral Collective facilities.
  9. Members agree NOT to consume or open any cannabis containers within 1000 feet of HashCentral Collective facilities or in any other place prohibited by law.
  10. Members agree NOT to sell or attempt to sell any cannabis acquired from HashCentral Collective .
  11. Members are allowed ONE medical cannabis purchase or ONE delivery per day.
  12. Members agree to abide by all requirements and restrictions regarding medical cannabis as set forth in Prop 215, SB420, California Health and Safety Code sections 11362.5 and 11362.7 et seq. and all local regulations.
  13. Members agree NOT to operate motor vehicles or other mechanical devices while medicated.
  14. Members must NOT bring any weapons or anything that can be used as a weapon to any HashCentral Collective facility. Pocket knives, tools etc. must be left in your vehicle or surrendered to HashCentral Collective staff or security while on the premises.

I UNDERSTAND AND AGREE TO THESE RULES AND REGULATIONS AS CONDITIONS FOR MEMBERSHIP IN HashCentral Collective AND AS REQUIRED TO ENTER ANY HASHCENTRAL COLLECTIVE FACILITY.

I have read the rules and regulations and agree to follow them