Caregiver License
INSTRUCTIONS
1. This form is to be completed by the parent or legal guardian of the minor patient (under age 18); or by an adult patient (age 18 or older) who
wishes to designate a licensed caregiver. Up to two parents/legal guardians may apply for a caregiver’s license for the minor patients.
2. This form is required to complete a caregiver license application and be approved for a caregiver license.
3. Only minor patients who have a physician certification of their medical need for a caregiver may have a licensed caregiver; the status of the
applicant as a minor alone does not qualify the applicant for a caregiver.
CAREGIVER DESIGNATION FORM
The patient is (select one):
2-Year Minor Patient 2-Year Adult Patient a 60-Day Minor Patient a 60-day Adult Patient
First Name Middle Name Last Name Suffix Date of Birth (mm/dd/yyyy)
Current Physical Street Address APT# City State ZIP
County Medical Marijuana Patient License Number
Patient Information
Caregiver Information
First Name Middle Name Last Name Suffix Date of Birth (mm/dd/yyyy)
Current Physical Street Address APT# City State ZIP
County Phone # Email Address
Relationship with Patient (select one):
SECOND CAREGIVER
First Name Middle Name Last Name Suffix Date of Birth (mm/dd/yyyy)
Current Physical Street Address APT# City State ZIP
County Phone # Email Address
Relationship with Patient
Custodial parent of minor patient
Legal Guardian of minor patient (must include documentation in application)
• I understand I am designating the individual identified above as my caregiver;
• This individual is a family member or assistant who regularly looks after me;
• I understand this individual cannot possess or purchase medical marijuana on my
behalf until he or she has been approved for and received a caregiver license; and
• I understand I can only have one designated caregiver licensed at any given time.
• I am a custodial parent or legal guardian of the minor patient.
• I understand that if I am a legal guardian I will need to provide official documentation proving my legal guardianship in my online application.
• I understand I will not receive a caregiver’s license until I complete a caregiver license application and am approved for a license.
Adult Patient Signature (If applicable)
Parent/Legal Guardian Signature (If applicable) Date (mm/dd/yyyy) Parent/Legal Guardian Signature (If applicable) Date (mm/dd/yyyy)
(select one):
FOR MINOR
PATIENTS
Date (mm/dd/yyyy)
FOR ADULT
PATIENTS
Caregiver of adult patient who is
a family member or assistant who
regularly looks after the adult patient
Custodial parent
of minor patient
Legal guardian of minor
patient (must include
documentation in application)
ATTESTATION By my signature below, I attest to the following:
ATTESTATION By my signature below, I attest to the following:
PAGE 1 OF 1OMMA.OK.GOV 405-522-OMMA Updated 4.22.2022
