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 Monday, September 5, 2022. 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 jumpstart@ppmny.org.
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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.)
Full name
How did you hear about the Jumpstart?
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From PPMNY
From Jewish Veg
From Rise Up East New York
From the Washington Heights & Inwood Food Council
From Yeshiva University's Care Café
From another community organization I'm connected to
From my workplace
From a friend or family member
Other
If you heard about the Jumpstart from someone involved with PPMNY, please enter their name here:
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.
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Motivation & Ability
Why are you interested in adopting a healthy plant-based diet? What motivates you to participate?
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What questions do you have about health and nutrition that you would like to explore in this program?
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These are the dates of our live virtual sessions. Please let us know which sessions you will be able to attend live. Note that attendance is strongly encouraged for ALL sessions, though recordings will be available.
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Orientation: Thursday, September 8, 7:00-8:30 PM ET
Prep session: Sunday, September 11, 3:00 - 6:00 PM ET
Day 1 kickoff: Sunday, September 18, 3:00 - 4:45 / 5:15 - 6:00 PM ET (a publicly available cooking demo)
Day 11: Wednesday, September 28, 7:00 - 9:00 PM ET
Day 15: Sunday, October 2, 3:00 - 5:00 PM ET
Day 22 closing celebration: Sunday, October 9, 3:00 - 5:00 PM ET
(For local participants only) Please choose the farmers' market tour you would like to attend. These will take place in the morning, though the specific time is TBD.
East New York (Brooklyn): Saturday, September 17, 10 AM
Grand Army Plaza (Brooklyn): Saturday, September 17
Union Square (Manhattan): Saturday, September 17
77th/79th Street Market (Upper West Side): Sunday, September 18, 10:30 AM
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.
Indicate which neighborhood or area would be most preferable for you to attend a market tour:
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Mentorship & Support
By dragging the items below, please rank your top 1-3 mentorship track themes from the list. Anything ranked 4 or lower will not be considered. Each track will consist of a group of 6-10 participants assigned to 1-2 peer Lifestyle Mentor(s) from the PPMNY community. We will confirm your mentorship track by Thursday, September 8.
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Preferred language for mentorship, if not English:
Español
Other
Select all times that you are available to attend mentorship sessions from September 15 - October 6. You will be assigned to a mentorship group meeting at only one of these times.
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Thursdays from 12:00 - 1:00 PM ET
Thursdays from 7:00 - 8:00 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 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.
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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.
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About Me & Food
How comfortable are you with preparing your own meals?
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Very comfortable
Somewhat comfortable
Somewhat uncomfortable
Very uncomfortable
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.)
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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.
Other
Approximately how many times each week do you prepare your own meals for lunch and dinner?
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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?
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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.
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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)
Other
Do you have any plant-food allergies or sensitivities we should be aware of?
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Medications
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.
Diabetes
Hypertension (high blood pressure)
I have not been diagnosed with any of the above but would like to speak with a medical partner.
Other
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.
Other
Do you have a primary care physician, or do you see a specialist who supports your medical care and/or medications/dosing?
Yes
No
Please select a time to speak with one of our medical partners about monitoring your medication with your personal physician.
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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:
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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:
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I consent.
I do not consent.
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Payment
Select the option that applies to you:
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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).
I have a discount code to participate at a lower rate (requires provided discount code)
Choose your payment level:
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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
Please choose your payment level:
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Sponsor rate - supports participation for you and one other: $250
Sustainer rate - pays for your participation: $136 ($14 discount for Jewish Veg participants)
Community rate - discounted rate for those who need it: $50
If you are sponsoring someone in particular, enter their name here:
Discount code:
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Choose your payment level here:
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Sponsor rate - supports participation for you and one other: $225
Sustainer rate - pays for your participation: $125
Community rate - discounted rate for those who need it: $25
Sponsorship coupon code:
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Scholarship coupon code
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