You will be given a paper copy to sign at your first Sanctuary Session

I, ______________________________________, for membership fee paid in hand, do hereby apply for

membership in DogFish Moon Sanctuary, a private membership organization. With the signing of this

membership agreement, I/we accept the offer made to become a member of DogFish Moon Sanctuary and

have read and agree with the following Declaration of Purpose from Article I of DogFish Moon

Sanctuary’s Articles of Association.

1. This Association of members hereby declares that our main objective is to maintain and improve the

civil rights, constitutional guarantees, and political freedom of every member and citizen of the United

States of America. We believe and affirm that the Constitution of the United States is one of the best

documents ever devised by man, and the signers of the Declaration of Independence did so out of love for

their country.

2. We believe that the First Amendment of the Constitution of the United States of America

guarantees our members the rights of free speech, petition, assembly, right to contract, and the right to

gather together for the lawful purpose of advising and helping one another in asserting our rights under the

federal and state constitutions and statutes. We strive to maintain and improve the civil rights,

constitutional guarantees, freedom of choice in health care and political freedom of every member of this

Association.

IT IS HEREBY Declared that we are exercising our right of “freedom of association” as

guaranteed by the First and Fourteenth Amendments of the U.S. Constitution and equivalent provisions of

the various state constitutions. This means that our Association activities are restricted to the private

domain only.

3. We declare the basic right of all our members to select spokesmen from our number who could be

expected to give wisest counsel and advice concerning the need for physical and mental health care

assistance and to select from our number those members who are the most skilled to assist and facilitate the

actual performance and delivery of care.

4. We proclaim the freedom to choose and perform for ourselves the types of therapies and modalities

that we think best for assessing and preventing illness of our minds and bodies and for achieving and

maintaining optimum wellness. We proclaim and reserve the right to include health options that include,

but are not limited to, cutting edge modalities and therapies practiced or used by any types of healers or

therapists or practitioners the world over, whether traditional or nontraditional, conventional or

unconventional.

5. The mission of our Association is to provide members with the highest level of quality care and the

most effective methods available. We emphasize our member’s health condition, and not merely the

symptoms experienced. Our Association understands that wellness has many dimensions and strives every

day to stay on the leading edge of new technology. The Association provides comprehensive,

conventional, complementary, alternative care and advanced technologies for all aspects of a member’s

health and provides the most effective means of care at an affordable fee. More specifically, our

Association provides members support and optimization of health and wellness through traditional and

alternative healing techniques. The Association aims to improve the living experience of members in their

physical, social emotional and environmental bodies and to provide holistic care and advanced

technologies. Accommodations may be available for members who desire the surroundings of a social,

emotional and environmental setting, which may include interacting with animals, to promote and

encourage health and wellness. Events may be offered for those members who wish to participate in

various occasions for the purposes of the Association for the benefit to its members.

6. The Association will recognize any person (irrespective of race, color, or religion) who is in

agreement with these principles and policies as a member and will provide a medium through which its

individual members may associate for actuating and bringing to fruition the principles and purposes

heretofore declared.

DogFish Moon Sanctuary

Membership Contract

Page 2 of 3

MEMORANDUM OF UNDERSTANDING

I understand that the fellow members of the Association that provide services and care, do so in the

capacity of a fellow member and not in the capacity as a licensed health care provider. I further understand

that within the association no doctor-patient relationship exists but only a contract member-member

Association relationship. In addition, I have freely chosen to change my legal status as a public patient or

client to a private member of the Association. I further understand that it is entirely my own responsibility

to consider the advice and recommendations offered to me by my fellow members and to educate myself as

to the efficacy, risks, and desirability of same and the acceptance of the offered or recommended diagnosis,

therapy, treatment and care is my own carefully considered decision. Any request by me to a fellow

member to assist me or provide me with the aforementioned diagnosis, therapy, treatment and care is my

own free decision in an exercise of my rights and made by me for my benefit, and I agree to hold the

Trustee(s), staff and other worker members and the Association harmless from any unintentional liability

for the results of such care, except for harm that results from instances of a clear and present danger of

substantive evil as determined by the Association, as stated and defined by the United States Supreme

Court.

The Trustee and members have chosen Frances R. Malone as the person best qualified to perform services

to members of the Association and entrust her to select other members to assist her in carrying out that

service.

In addition, I understand that since the Association is protected by the First and Fourteenth Amendments to

the U.S. Constitution, it is outside the jurisdiction and authority of Federal and State Agencies and

Authorities concerning any and all complaints or grievances against the Association, any Trustee(s),

members or other staff persons. All rights of complaints or grievances will be settled by an Association

Committee and will be waived by the member for the benefit of the Association and its members. Because

the privacy and security of membership records maintained within the Association which have been held to

be inviolate by the U.S. Supreme Court, the undersigned member waives HIPAA privacy rights and

complaint process. Any medical or healthcare records kept by the association will be strictly protected and

only released upon written request of the member. I agree that violation of any waivers in this membership

contract will result in a no contest legal proceeding against me. In addition, the Association does not

participate in any medical insurance plans or collections on behalf of the member but will provide a

suitable invoice for the member to pursue reimbursement by his/her insurance company, if applicable.

I agree to join the Association, a private membership association under common law, whose members seek

to help each other achieve better health and live longer with good quality of life.

I understand that the doctors, nurses, and other providers who are fellow members of the Association are

offering me advice, services, and benefits that do not necessarily conform to conventional medical care. I

do not expect these benefits to include on-call coverage, hospital care, or the usual and customary care

provided by most physicians. I will receive such primary and specialist care elsewhere. I fully understand

that the benefits I receive from the Association might or might not be covered by my health insurance and

not at all by Medicare.

As a member, I accept the goals of helping my body function better and choosing techniques that are both

very safe and have a reasonably good chance to succeed, realizing that no diagnostic technique or treatment

is foolproof. If I choose to forgo drugs, surgery, or radiation that has been recommended to me by others, I

fully accept the risk that I might suffer serious consequences from that choice. Other aspects of informed

consent will take place in my discussions with the providers and my fellow members of the Association.

My activities within the Association are a private matter that I refuse to share with the State Medical Board,

the FDA, FTC, Medicare, Medicaid or my own insurance company without my expressed specific

permission. All records and documents remain as property of the Association, even if I receive a copy of

them. I fully agree not to file a malpractice lawsuit against a fellow member of the Association unless that

member has exposed me to a clear and present danger of substantive evil. I acknowledge that the members

of the Association do not carry malpractice insurance.

DogFish Moon Sanctuary

Membership Contract

Page 3 of 3

I enter into this agreement of my own free will or on behalf of my dependent without any pressure or

promise of cure. I affirm that I do not represent any State or Federal agency whose purpose is to regulate

and approve products. I have read and understood this document, and my questions have been answered

fully to my satisfaction. I understand that I can withdraw from this agreement and terminate my

membership in this association at any time. These pages and Article I of the Articles of Association of the

Association consist of the entire agreement for my membership in the Association and they supersede any

previous agreement.

I understand that the membership fee entitles me to receive those benefits declared by the Trustee(s) to be

“general benefits” free of further charge. I agree to pay as levied those benefits that I receive that are

declared by the Trustees to be “special assessments”, per Fee Schedule.

I enclose the sum of $7.00 as consideration for my one-time lifetime membership contract, said term

beginning with the date of the signing of this contract, and by these presents do hereby certify, attest and

warrant that I have carefully read the above and foregoing DogFish Moon Sanctuary’s Contractual

Application for Membership and I fully understand and agree with same.

IN WITNESS WHEREOF I set my hand this ______day of _____________________, 20____.

______________________________________________________________________________

Member’s Name (Name of legal guardian if Applicant under 18 years, if applicable)

______________________________________________________________________________

Member’s Signature (Signature of legal guardian if Applicant under 18 years, if applicable)

Member’s Contact Information:

______________________________________________________________________________

Street City State Zip Code

__________________________________________ ________________________________

home/work/cell numbers email address

DogFish Moon Sanctuary

By_________________________________________

Approved and accepted this ____ day of ________________________, 20____.