Marijuana Request Form

Marijuana and Medication Lock Bag Request Form

This is a request form to fill out for those who wish to receive a free marijuana/medication lock bag from the health department. After completing this form you will be contacted on where to pick up your lock bag within 48 hours.
PLEASE NOTE: This is only available for Montcalm and Clinton County residents.
Name*

First NameLast Name
E-mail
example@example.com
Phone Number*
Format: (000) 000-0000.
County of Residence*
Yes - at a health department branchYes - at a libraryYes - otherNo
YesNoNo, but children visitNo, lock bag will be used for other purpose (explain below)
How will you use this lock bag (i.e. for marijuana use, medication, other)?
Do you want additional information on marijuana use? If yes, how would you like to be contacted?
Please note: This is only available for Montcalm and Clinton County residents at this time.
Should be Empty:

Marijuana and Medication Lock Bag Request Form