CONSENT TO PARTICIPATE
365 Days Obesity Challenge of Brooklyn
Thank you for your interest in the 365 Days Obesity Challenge of Brooklyn, a community-based wellness initiative designed to promote healthy lifestyle changes through educational sessions and supportive resources.
Please read the information below carefully before giving your consent.
1. Purpose of the Program
The 365 Days Obesity Challenge is a non-clinical educational program. It does not involve medical diagnosis or treatment. However, to support participants in tracking their wellness progress, we will monitor basic health indicators over time.
2. Information Being Collected
As part of your participation, we may collect the following:
Contact Information:
- Full Name
- Phone Number
- Email Address
Health Parameters for Progress Monitoring:
- Body Weight / BMI
- Waist Circumference
- Blood Pressure
- HbA1c (blood sugar control marker)
- Lipid Profile (cholesterol and triglycerides)
All health indicators are collected with your consent and for personal progress tracking only. Results will not be used to diagnose or treat medical conditions.
3. How Your Information Will Be Used
Your information will be used to:
- Track and communicate your progress in the program
- Share wellness and nutrition-related educational content
- Connect you with approved program partners delivering support sessions
4. Sharing with Program Partners
Your contact information may be shared only with authorized program partners:
- Plant Powered Metro New York, Inc. (nutrition education team)
- Flow and Restore Yoga
- 120/80 Project
- Inclusive Insurance Agency
Your contact information and basic health indicators may be shared only with:
- American College of Physicians
- Janice's Prime Care platform (data management and secure storage)
These partners will only use your data for the purposes outlined in this consent and will maintain confidentiality and privacy in accordance with applicable guidelines.
5. Your Rights
- Your participation is voluntary, and you may withdraw at any time.
- You can request to have your data deleted by contacting us at jpc.drshukla@gmail.com or 718-400-6951 (dial option 4).
- You can choose which health indicators you consent to provide.
6. Consent Statement
By signing below, I acknowledge that:
- I understand the nature and purpose of the program.
- I voluntarily agree to participate in the 365 Days Obesity Challenge of Brooklyn.
- I consent to the collection and secure sharing of my contact information and selected health indicators with the program team and its partners for non-clinical progress tracking purposes.
By Registering, you consent to share:
- ☐ Body Weight / BMI
- ☐ Waist Circumference
- ☐ Blood Pressure
- ☐ HbA1c
- ☐ Lipid Profile
We may contact you by email or phone provided by you.
Consent for Photography and Videography
By participating in this program, I hereby grant permission to 365 Days Obesity Challenge of Brooklyn to take photographs and record videos of me during the course of the event.
I understand that these images and recordings may be used for promotional purposes, including but not limited to:
- Social media posts
- Website content
- Printed materials (brochures, flyers, reports)
- Press releases or media coverage
I consent to the use of these materials without compensation and waive any rights to inspect or approve the finished product.
