Fall 2023 Jumpstart Registration

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 Wednesday, October 18.*
Preferred language for mentorship, if not English:

EspañolOther
Select all times that you are available to attend mentorship sessions on Wednesdays, October 25, November 1, and November 8. You will be assigned to a mentorship group meeting at only one of these times.*

12:00 - 1:00 PM ET7:00 - 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.

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. If you will not be scheduling an intake call, you can skip to the next page.

DiabetesHypertension (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.Other
Do you have a primary care physician, or do you see a specialist who supports your medical care and/or medications/dosing?*

YesNo
Please select a time to speak with one of our medical partners about monitoring your medication with your personal physician.

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:*

Clear
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 consent.I do not consent.

21-Day Plant Powered Jumpstart: Fall 2023 Registration

Motivation & Ability

Mentorship & Support

About Me & Food

Medications

Final Thoughts & Waivers

Payment