Caregivers looking to receive their Medical Marijuana Caregiver REgistration should fill out the form below. One of our staff members will follow up with you to complete your registration. If you have any issues, please call us at 816-944-3654 In addition to this form, you will need a Patient Authorization Form completed by a patien. If you have any issues, please call or text us at 816-944-3654 Legal First Name Legal Last Name Telephone Number Email Address for State Registration Create a Password for State Login SSN Date Of Birth Street Address City State Zip Code County If you have any issues, please call or text us at 816-944-3654 State Issued ID Front Facing Photo (A selfie showing your shoulders and above) After you click submit, your card will be charged for $50. Your receipt will be emailed to the email above and you will be contacted by a Bluebird Wellness Center specialist to complete your registration. I agree to the Terms & Conditions
