Membership

I hereby appoint Emerald Cross as my agent for the sole purpose of procuring substances which I may order for my personal medical use. I made this appointment on my own free will and acknowledge that no effort has been made by to encourage me to procure or use any product. I acknowledge that no effort has been made by Emerald Cross to encourage me to procure, purchase or use any substance, nor has any claim been made regarding the usefulness, efficacy, performance, safety or legality of any substance I may acquire through Emerald Cross .
I understand donations to Emerald Cross, for any medical needs I may acquire through the organization, includes a nominal processing fee to offset expenses, and that this transaction in no way constitutes a commercial sale.
In consideration of services provided by Emerald Cross, I hereby agree, for myself, my heirs and assigns to hold Emerald Cross and anyone acting on their behalf free and harmless from any liability out of my procurement and/or use of any substance which I obtain through Emerald Cross.

Signed: _________________________________ Date:______
Print Name: ______________________________DOB:______
Address: __________________________________________
City:__________________________ State: _____ Zip:______
Phone:______________________ Cell: __________________
E-mail: ______________________________


		Emerald Cross Membership Application & Informed Consent I hereby appoint Emerald Cross as my agent for the sole purpose of procuring substances which I may order for my personal medical use. I made this appointment on my own free will and acknowledge that no effort has been made by to encourage me to procure or use any product. I acknowledge that no effort has been made by Emerald Cross to encourage me to procure, purchase or use any substance, nor has any claim been made regarding the usefulness, efficacy, performance, safety or legality of any substance I may acquire through Emerald Cross . I understand donations to Emerald Cross, for any medical needs I may acquire through the organization, includes a nominal processing fee to offset expenses, and that this transaction in no way constitutes a commercial sale. In consideration of services provided by Emerald Cross, I hereby agree, for myself, my heirs and assigns to hold Emerald Cross and anyone acting on their behalf free and harmless from any liability out of my procurement and/or use of any substance which I obtain through Emerald Cross. Signed: _________________________________ Date:______ Print Name: ______________________________DOB:______ Address: __________________________________________ City:__________________________ State: _____ Zip:______ Phone:______________________ Cell: __________________ E-mail: ______________________________ FAX COMPLETED FORM TO EMERALD CROSS AT: 206-382-7498