Before you start…

Please be sure to have a digital copy of your government-issued ID and your prescription (if, available) to sign up.

Membership Registration Form

I AM…

I am a frontline worker (nurses, police, firefighters, etc..)

Did you know: As a frontline worker, you’re automatically enrolled in compassionate (aka. discounted) pricing program.

ORGANIZATION NAME(Required)

ORGANIZATION REPRESENTATIVE NAME(Required)

PATIENT NAME(Required)

First Middle Last

PHONE NUMBER(Required)

EMAIL(Required)

This is the main method of communication.

PRESCRIPTION(Required)

Prescription Transfer Instructions

Please reach out to your prescriber and ask them to fax your prescription to us at 1-604-696-3745. Once we receive your prescription, we will setup your account shortly.

COMPASSIONATE PRICING OPTION

WOULD YOU LIKE ACCESS TO COMPASSIONATE (DISCOUNTED) PRICING?(Required)

DEMOGRAPHIC DATA

Please complete some details below to gain access to compassionate (deeply discounted) pricing.

PERSONAL HEALTH NUMBER

VETERAN'S SERVICE NUMBER

Did you know: You are eligible for 150g of FREE cannabis flowers per month as a registered veteran with a cannabis prescription?

DATE OF BIRTH(Required)

Month

Day

Year

SEX(Required)

ETHNIC ORIGIN(Required)

Black (Examples: African, Afro-Caribbean, African-Canadian descent)

East Asian (Examples: Chinese, Korean, Japanese, Taiwanese descent)

Latino (Examples: Latin American, Hispanic descent)

Middle Eastern (Examples: Arab, Persian, West Asian descent, e.g. Afghan, Egyptian, Iranian, etc.)

South Asian (Examples: South Asian descent, e.g. East Indian, Pakistani, Sri Lankan, Indo-Caribbean, etc.)

Southeast Asian (Examples: Filipino, Vietnamese, Cambodian, Thai, other Southeast Asian descent)

White (Example: European descent)

Not Listed

FINANCIAL STATUS(Required)

please select all that apply

Income Assistance

Old Age Pension

less than $19,999

$20,000-$34,999

$35,000-$49,999

> $50,000

No Income

WORK STATUS(Required)

please select all that apply

Unemployed

On leave

Full-time

Part-time

Disabled

LIVING SITUATION(Required)

Please list all applicable conditions you are hoping medical cannabis will help with.(Required)

FILE UPLOADS

GOVERNMENT-ISSUED PHOTO ID(Required)

Max. file size: 400 MB.

MEDICAL DOCUMENT / PRESCRIPTION(Required)

Max. file size: 400 MB.

TERMS & CONDITIONS / PRIVACY POLICY

Acknowledgement(Required)

I agree to the Terms & Conditions and Privacy Policy.

High Hopes Inc (“High Hopes”) is required to collect the information of the Applicant pursuant to the Cannabis Act as may be amended from time to time.

High Hopes collects, uses, and discloses personal information only in accordance with the provisions of the Personal Information Protection and Electronic Documents Act, the Cannabis Act, and High Hopes’ Privacy Policy. Any information collected by opting in to receive correspondence from High Hopes is retained and disclosed in strict accordance with our privacy policy which can be viewed in full on our website.

• The Applicant acknowledges that medical cannabis is not approved for use as a drug in Canada and that its risks and appropriate dosages have not been determined. The Applicant acknowledges that he/ she is using medical cannabis at his/her own risk and that High Hopes is not liable for any damages, loss, or injury whatsoever that results, either directly or indirectly, from the use of medical cannabis.

• The Applicant acknowledges that some of the information provided in this document may be shared with our service providers for shipping purposes only.

• The Applicant ordinarily resides in Canada.

• The Applicant acknowledges that, where the Applicant has been referred to High Hopes by a third-party intermediary (i.e., your physician/ clinic), High Hopes may share some personal information collected by High Hopes, including information provided in this document, with the applicable third-party intermediary.

• The information in this application and the Medical Document or Registration Document is correct and complete.

• The original Medical Document or Registration Document submitted to High Hopes by yourself, or your physician is not being used to seek or obtain medical cannabis from another source.

• The original of Medical Document accompanies the application.

• The Applicant will use medical cannabis only for their own medical purposes.

• The Applicant agrees that High Hopes may collect, use, disclose and store his/her personal information and personal health information provided by the Applicant, his/her caregiver or his/her health care professional(s) (collectively, the Applicant’s “information”) to determine his/her eligibility for, and registration as, a client of High Hopes, and for the purpose of filing orders and providing information about High Hopes and its products and services and for the purpose of obtaining and processing payments by, or on behalf of, the Applicant as applicable.

• The Applicant acknowledges that, when applicable, High Hopes may speak with, and share information with, the Applicant’s health insurer, union, or private benefit provider to maximize the available benefit(s) to the Applicant.

Please give us 24-48 hours to verify your prescription. Once approved, we will send you a login so you can start ordering.