Ahara Kula Participation Application and Permission Form
Please fill out this form to confirm eligibility and permission to participate in the Ahara Kula research study. Simply scroll down to fill in the required fields.
Full Name
First Name
Last Name
Email Address
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Birth
-
Month
-
Day
Year
Date
Are you a woman between the ages of 18 and 70?
Please Select
Yes
No
Are your current health issues managed?
Please Select
Yes
No
I Would Like to Discuss
Do you have internet access and zoom capabilities?
Please Select
Yes
No
Are you willing to complete the study forms (minimal), undertake the weekly classes (live or recorded), and maintain a reflection journal?
Please Select
Yes
No
Are you willing to complete the study forms (minimal), undertake the weekly classes (live or recorded), and maintain a reflection journal?
Please Select
Yes
No
Do you agree to participate in this research study including data collection (any data collection and analysis will be strictly confidential and anonymous)?
Yes
No
Do you give consent to share media and statistical findings (anonymous and faceless).
Yes
No
Please feel free to add any additional comments or questions you may have.
Signature
*
Submit
Submit
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