Patient Waiver of Liability and Hold Harmless Agreement

I,



am fully aware of the risks and hazards (legal, medical, so­cial, and otherwise) involved with acquiring and using approved medical marijuana products I obtain from Columbia Care New York ("Dispensary") for any purpose, medical or otherwise. I am fully aware that there may be risks and hazards unknown to me, the Dispensary, Dispensary agents, or any other person with whom I have consulted.  

I voluntarily assume full responsibility for any risk, loss, damage, or personal injury (including death) that I sustain as a result of being a customer of Dispensary and/or my possession or use of marijuana.

I hereby indemnify and hold harmless Dispensary and its affiliates, officers, directors, agents, representatives, and employees from and against any and all damages, liabilities, obligations, penalties, fines, judgments, claims, deficien­cies, losses, costs, and expenses (including attorneys' fees and costs) arising out of resulting from, or in any way related to: (i) my being a customer of Dispensary; (ii) the status of any of my licenses or registration cards; or (iii) my possession or use of marijuana or any other controlled substance.

It is my express intent that this Waiver of Liability and Hold Harmless Agreement (the "Release") bind the mem­bers of my family and spouse if I am alive, and my heirs, assigns, and personal representative if I am deceased, and that the Release is deemed a release, waiver, discharge, and covenant not to sue Dispensary or any of its affiliates, officers, directors, agents, representatives, and employees.

In signing this Release, I acknowledge and represent that:

• I have read the foregoing release and indemnification, understand the entire Release, and sign it voluntarily;
• No representations, statements, or inducements (oral or otherwise), apart from the foregoing written agreement, have been made to me regarding medical marijuana or Dispensary;
• I am at least 18 years of age and fully competent; and I execute this Release for full, adequate, and complete con­sideration fully intending to be bound by the same. Dispensary is relying on this Release in the provision of any services or products to me.
• I have complied with all applicable New York Department of Health regulations regarding the acquisition, use, and possession of medical marijuana, including being in possession of a valid State-issued Registry Identification Card.
• I give authorization as a registered patient in the New York State Medical Marijuana Program and a customer of Columbia Care NY Medical Marijuana Dispensary that Columbia Care NY may track my prescribing history.

Date

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Dispensary Agent Signature

*In the event, if the patient is under 18 years old, a legal guardian must execute this Release on behalf of the patient.

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