2024 Clean Eating Challenge Application

Company

Name

First NameLast Name

Title

Email

example@example.com

Phone Number

Please enter a valid phone number.

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

How did you hear about the challenge?

I have participated in a diet and/or health and wellness program in the past.

YesNo

If you have participated in a program in thepast, what was the timeframe of participation?

0-6 months ago6-12 months agoMore than a year ago

My reasons for participating are: (Check all that apply)

Goal Weight

Goal Fruit & Vegetable Consumption (per day)

Goal Physical Activity (mins or steps / day)

Other Goal

I plan to take advantage of the following Challenge provided resources: (Check all that apply)

Mentoring Team CallsMentoring Text ExchangesNutritionist Group CallsNutritionist One on One Calls

I agree to get bloodwork done as part of the challenge participation and share this with Clean Eating Challenge Chairperson, Mentor and Nutritionist

I Accept

I acknowledge that as a participant of the Clean Eating Challenge I will be asked to document and share my progress every month via blog or vlog which will be posted on the Clean Eating Challenge website.

I Understand

I accept that as a member of the challenge, I am expected to engage with my mentor on a weekly basis for the duration of the challenge.

I Accept

I would like a mentor group that shares the following characteristics (please rank in order of preference)

Do you have a

FitbitApple Watch

Finally, please share with us your “WHY” for wanting to participate in the Clean Eating Challenge. (100-300 words)

0/300

Consent:
I am being asked to read the following material to ensure that I am informed of the nature of this program and of how I will participate in it, if I consent to do so. Signing this form will indicate that I have been so informed and that I give my consent. My written informed consent is necessary prior to participation in this program so that I can know the nature and risks of my participation and can decide to participate or not participate in a free and informed manner.

The Viva Fresh Clean Eating Challenge, hosted by the Texas International Produce Association (TIPA) is a voluntary wellness program meant to improve your overall health and well-being through diet and exercise. TIPA is not authorized to provide medical advice or direction and you should speak with a physician before participating in any diet or exercise program especially if you have not participated in a physical activity program for several years or if you have been diagnosed with any of the following: cardiovascular disease, cancer (recently or currently in treatment), lung disease such as COPD or asthma, diabetes, hypertension, rheumatoid arthritis or are taking any immunosuppressant medication.

This program will remain voluntary throughout its duration and will provide access to tools and resources, as well as best practices including eating more fruits and vegetables and getting 10,000 steps per day. Resources suggested may include workouts, recipes, meal plans and expert or peer support but TIPA makes no claims to the validity of these resources for each individual and expectations should include the fact that results may vary.

All information you provide here and throughout the challenge is confidential unless you opt in as a featured participant or to have your information shared as part of group data only.

This program is free of cost and there is no charge to join or participate other than any additional medical or other related resources you would choose to secure on your own.

Participant Signature

Clean Eating Challenge Application

Additional Background Information

My Challenge Goals Are