Illinois Department of Public Health s2

Illinois Department of Public Health

Medical Cannabis Registry Program

Patient Application Training Registration Form

The purpose of this training is to understand the patient application process for adult and minor qualifying patients who wish to register for the Illinois Medical Cannabis Registry Program. The training will provide a step-by-step overview of the application and the information needed to successfully apply for the program.

When: January 25, 2017

9:00 AM to Noon

Location: The Michael A. Bilandic Building

Conference Room C-500 – 5th Floor

160 North LaSalle, Chicago, Illinois

Who: Persons seeking to apply for the program or who are assisting others with completing an application for a medical cannabis registry identification card.

Name *
Organization * Name/Company Affiliation / ¨ Not Applicable
Address *
City, State, Zip *
Phone *
Email Address *

* Denotes mandatory field

Visit www.IDPH.illinois.gov for more information about the Illinois Medical Cannabis Registry Program

Fax or email this registration to 217-782-1321 or