Membership Application & Informed Consent

I hereby appoint Green Cross Patient Co-op of Seattle 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 Green Cross Patient Co-op of Seattle 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 Green Cross Patient Co-op.

I understand that donations to Green Cross Patient Co-op of Seattle, 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 promotion.

In consideration of services provided to me by Green Cross Patient Co-op, I hereby agree, for myself, my heirs and assigns to hold Green Cross Patient Co-op 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 Green Cross Patient Co-op of Seattle.

Signed: ______________________________________ Date:_____________ 

Name (Printed):__________________________________________________ 

Address: ________________________________________________________ 

City: _____________________________State: _________ Zip: ___________ 

Phone: _________________________ Fax:___________________________ 

E-mail: ___________________________________ 

FAX COMPLETED FORM TO GREEN CROSS PATIENT CO-OP AT: 206-763-9855