21-Day Plant Powered Jumpstart Registration
Plant Powered Metro New York (PPMNY) is excited to welcome you into our 21-Day Plant Powered Jumpstart! This whole food, plant-based (WFPB) nutrition jumpstart is designed to introduce you to evidence-based principles of healthy eating and provide you with support to make substantial dietary change for health and healing. Please complete this registration form no later than Sunday, October 17th. Note that by registering for this program you are communicating your readiness to adopting the dietary guidelines of a whole food, plant-based diet for 21 days. For further information, visit https://www.plantpoweredmetrony.org/jumpstarts.html. Please direct any questions to firstname.lastname@example.org.
Preferred e-mail address
Home address *with apartment number, if applicable*
Street Address Line 2
Antigua and Barbuda
Bosnia and Herzegovina
Central African Republic
Cocos (Keeling) Islands
Democratic Republic of the Congo
Turkish Republic of Northern Cyprus
Papua New Guinea
Republic of the Congo
Saint Kitts and Nevis
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Sao Tome and Principe
Trinidad and Tobago
Tristan da Cunha
Turks and Caicos Islands
United Arab Emirates
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Preferred phone number
Date of birth
If you are participating with someone else -- like a family member, friend, or colleague -- share their name(s) here. (Note that each adult requires separate registration, but we'd like to know who is signing up together.)
How did you hear about the Jumpstart?
From my workplace
From a community organization I'm connected to
From a friend or family member
PPMNY has a limited number of produce boxes to distribute to local jumpstart participants (in NYC and surrounding counties) who experience hardship accessing or affording fresh vegetables. Please indicate here if you would like to receive a box, and we will do our best to fulfill as many requests as possible.
I would like to receive a box.
Please provide any necessary delivery instructions for the produce company here.
Motivation & Ability
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?
Will you be able to attend the orientation session on Wednesday, October 20th, from 7:00 - 9:00 PM EDT?
Indicate which virtual sessions you will be able to attend live. Note that attendance is strongly encouraged for ALL sessions, though recordings will be available.
Day 1 Kickoff: Sunday, October 24, 2:00 - 6:00 PM EDT
Day 8: October 31, 2:00 - 5:00 PM EDT
Day 15: Sunday, November 7, 2:00 - 5:00 PM EST
Day 22 Closing Celebration: Sunday, November 14, 2:00 - 4:00 PM EST
(For local participants only) Please choose the farmers' market tour you would like to attend. All market tours are scheduled for the morning of Saturday, October 30th, though the specific time is TBD.
Union Square Market (Manhattan)
Grand Army Plaza (Brooklyn)
I would like to participate in a tour closer to where I live or on another day of the week, if other tours are planned.
Mentorship & Support
Please rank your top 1-3 mentorship tracks from the list below (by dragging). Anything ranked 4 or lower will not be considered. Each track will consist of a group of 6-10 participants assigned to a peer Lifestyle Mentor from the PPMNY community. We will confirm your mentorship track by Wednesday, October 20th.
Preferred language for mentorship, if not English:
Select all times that you are available to attend mentorship sessions. Only one time will be chosen.
Wednesdays from 12:00 - 1:00 PM ET
Wednesdays from 7:30 - 8:30 PM ET
Thursdays from 7:30 - 8:30 PM ET
Please let us know if you would like to participate in one of these platforms for group support during and after the program. All platforms can be used through a mobile app or computer. Check all that apply.
I am interested in joining a private Facebook group for past and current jumpstart participants.
I am interested in joining a Slack channel for a group chat with all current participants.
I am interested in joining a WhatsApp group chat with my mentorship track.
We will be providing all Jumpstart materials at your fingertips through a special program app and other app-based resources. Please choose the statement that best reflects you.
I am comfortable using apps on my phone.
I will need some support accessing and using apps, but I'm open to learning.
I don't use apps and now isn't the right time for me to learn.
I don't have a smartphone.
About Me & Food
How comfortable are you with preparing your own meals?
Tell us about you and your kitchen. Check any that apply. (Note that any tools mentioned below are not required or necessary to participate in the program.)
I have time to spend in the kitchen.
I like to work from recipes.
I like to work with precut/frozen/canned ingredients.
I feel comfortable working with knives.
I have good kitchen tools.
I have a high-speed blender.
I have a slow cooker.
I have a pressure cooker.
Approximately how many times each week do you prepare your own meals for lunch and dinner?
6-7 days of the week
3-5 days of the week
1-2 days of the week
Never - someone else prepares my meals
Never - I always (or almost always) eat out or take in
How often do you eat outside the home or take in food?
Never, or almost never
A few times a month
A few times a week
Daily, or almost daily
Multiple times daily (like lunch and dinner most days)
Select whichever options below best describe what you currently eat. Check any that apply.
Omnivore (regularly eat meat)
Semi-vegetarian (only occasionally eat meat)
Pescatarian (fish, dairy, and eggs, but no meat)
Lacto-ovo vegetarian (dairy and eggs, but no meat or fish)
Vegan (no animal products)
Whole food, plant-based (little-to-no animal or processed foods)
Do you have any plant-food allergies or sensitivities we should be aware of?
The information in this section is being collected to ensure participant safety and will only be used by PPMNY's jumpstart leaders and our medical advisors. We request your honest disclosure. By answering these questions you affirm that they are true; please do not withhold information. **If you are on medication for diabetes or hypertension (high blood pressure), we require a brief intake call with one of our medical partners; you will be prompted through this registration form to sign up for a time to speak with them. In addition, it is essential that you work with your personal physician to monitor your medications over the course of the program, as you may need to reduce your dosages if you follow the dietary guidelines closely.
Have you been diagnosed with the following conditions? Check any that apply. Note that you are welcome to meet with a medical partner even if you have not been diagnosed with the below conditions.
Hypertension (high blood pressure)
I have not been diagnosed with any of the above but would like to speak with a medical partner.
Are you on any medications for the above condition(s)? Check any that apply.
I am on a blood pressure lowering medication.
I take insulin.
I use another non-insulin diabetes medication.
Do you have a primary care physician, or do you see a specialist who supports your medical care and/or medications/dosing?
Please select a time to speak with one of our medical partners about monitoring your medication with your personal physician.
Is there anything else we should be aware of?
Final Thoughts & Waivers
Do you have any other questions or concerns about the Jumpstart program?
To complete the enrollment process, you must read and agree to BOTH of the following forms.
By signing, you agree to the content outlined in the two waivers above:
Consenting to the following waiver is not mandatory for participation in the program.
Select whether you consent or do not consent to the above publicity release waiver:
I do not consent.
Select the option that applies to you:
I am paying for my own participation.
I am being sponsored by an organization to participate for free (requires provided coupon code).
I have received a scholarship to participate in this program (requires provided scholarship code).
Please choose your payment level.
Sponsor rate - supports participation for you and one other: $250
Sustainer rate - pays for your participation: $150
Community rate - discounted rate for those who need it: $50
Sponsorship coupon code:
Scholarship coupon code
I would like to add a donation to my payment in the amount of:
( X )
Pay with Credit Card
Debit or Credit Card
Credit Card Number
Please click one of the PayPal options to complete payment and
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