Winter 2019 Plant Powered Jumpstart: Participant Interest Form

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Plant Powered Manhattan and Marlene Meyerson JCC Manhattan are gauging interest to offer this 21-day community-based wellness project, supporting you in diving into a healthy plant-based lifestyle, learning new skills and habits, and demonstrating real quantifiable impact.

Please complete this interest form by Wednesday, January 16th so that we can design an experience that will meet your needs. Should the program proceed, we expect that it will take place during the month of February.

Name *

Email *

Address *

Zip Code *

Preferred phone number *

Why are you interested in adopting a healthy plant-based diet? What motivates you to participate? *

What questions do you have about health and nutrition that you would like to explore in this program? *

Are you ready and available to commit to following the dietary guidelines of the program for a full 21 days during the month of February? (Please note that travel and other commitments may complicate your situation.) *

Yes

Are you open and committed to the use of biometric testing to establish an initial health baseline and offer concrete results at the program's conclusion? (Participants will liaise with program coordinator for scheduling) *

Yes

Are you able to pay a program fee? *

Yes

Yes, if not too high.

I would participate in the program if it was:

$20 per day = $420

$15 per day = $315

$10 per day = $240

$5 per day = $105

I will indicate what I can contribute in the following section

Is there anything else you would like us to know?

Submit

Clear form

Never submit passwords through Google Forms.

This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy

Forms