Participant Registration
- Name (First Last) *
- email address *
- Best Contact Phone Number *(###)-###-####
- Date of Birth (mm/dd/yyyy) *
- Nearest Major City *
- Start Date (1st day of 30 days)MM/DD/YYYY
- Start Weight (in pounds) *You can enter your present weight if you're completing this registration before you receive the product but please check your weight again the day you begin. If it has changed, resubmit this form or send an email noting the revised start weight to phil@philkaplan.com, copied to stacey@philkaplan.com
- Present Exercise Habit *Choose the one that best applies
- Submit a brief paragraph describing your exercise and diet history *
- Please check one *I have already ordered my AMASAI and REIGN water for the studyI am planning on placing my order but have not as of yetI have additional questions and would like someone to contact me before I place my order
- Access to Body Composition Testing *I have a personal trainer who can assess body composition with a skinfold caliper before and after the 30 day periodI do not presently know a personal trainer who can assess body composition
- If you do have a personal trainer, please provide his or her name
- Please check one of the following related to your AMASAI selection *In hope of optimal results, I've opted for only Plain AMASAI (recommended). I can use a handful of organic blueberries and plain stevia to add flavor if desired without compromising resultsI want to enjoy the best taste so I've opted to use flavored AMASAI. I realize the additional glucose may hinder results but feel this will lead to better adherenceI was undecided so I've opted to order variety packs
- Feel free to add any additional thoughts or comments
- Commitment (please check box, then submit)I am fully committed to this program and realize that the study relies on adherence and honesty. I have every intention of using 8 ounces of AMASAI as my morning meal and consuming two fruit-infused REIGN waters each day for 30 days. If I find it difficult to stick to the program, I will email Phil Kaplan (phil@philkaplan.com) asking him not to include my results in the actual study. Even if I withdraw from the study, i will track my weight changes over the 30 days.
