INFORMED CONSENT FOR PARTICIPATION IN THE NEW AMERICAN PLATE CHALLENGE PROGRAM AND RELEASE FROM LIABILITY
- PURPOSE OF THE PROGRAM:
You have been accepted to participate in the New American Plate Challenge program (the “Program”) because you have expressed interest in more healthful eating and/or losing weight and potentially lowering your cancer risk. The purpose of the Program is to teach you how to easily and independently apply the food portion and proportion principles of the New American Plate (“NAP”) with the goal of losing weight and, potentially, lowering cancer risk. Your participation in this Program is expected to last for the twelve week challenge period.
Previous research has demonstrated that the risk of developing certain kinds of cancer may be reduced through healthy eating and physical activity. The American Institute for Cancer Research (“AICR”), the sponsor of the Program, has developed a web based weight loss program to assist in applying such principles.
III. WHAT WILL BE DONE:
Once you have completed your online Challenge Sign-Up Questionnaire, you will receive in your email the weekly NAP nutrition and physical activity challenges. Each of the twelve challenges will have visual cues, background information, tips/action steps and website links for additional information.
During the Challenge period, you will have your own page with your personal blog, the ability to track your own weight, and access to a forum to discuss progress and obstacles with other participants. You will also be encouraged to share photos of your plate and physical activity. AICR dietitians will also provide general, educational feedback and encouragement on the sharing forum, as appropriate.
- POSSIBLE BENEFITS:
You may benefit from participation in this Program if the tools you receive and information you learn help you to maintain a more healthy diet and improved level of exercise. It will not, however, be possible to determine whether or not participation in the Program will actually decrease your risk of developing any particular cancer.
- POSSIBLE RISKS:
You understand that the Program will include physical activity challenges, which potentially could result in injury. By admitting you as a participant in the Program, AICR is not making any medical judgment about your physical ability to complete the NAP nutrition and physical activity challenges. If you have any dietary or physical restrictions, or any other concerns about your participation in the Program, you should discuss your concerns and potential participation in the Program with your primary physician. You, together with your physician, should make an independent determination of whether it is appropriate and advisable for you to participate in the Program.
- WAIVER AND RELEASE OF LIABILITY:
YOU ACKNOWLEDGE AND FULLY UNDERSTAND THAT, AS A PARTICIPANT IN THE PROGRAM, YOU WILL BE ENGAGING IN ACTIVITIES THAT INVOLVE RISK OF INJURY. YOU FURTHER ACKNOWLEDGE THAT THERE MAY BE RISKS NOT KNOWN TO YOU OR REASONABLY FORESEEABLE. YOU EXPRESSLY ASSUME ALL RISKS OF INJURY, INCLUDING PERMANENT DISABILITY OR DEATH, WHICH MAY OCCUR IN CONNECTION WITH YOUR PARTICIPATION IN THE PROGRAM. YOU UNDERSTAND THAT PARTICIPATION IN THE PROGRAM IS STRICTLY VOLUNTARY AND YOU ARE FREELY CHOOSING TO PARTICIPATE.
YOU RELEASE, WAIVE AND DISCHARGE AICR, AND EACH OF ITS AFFILIATES AND RELATED ENTITIES, AND THEIR RESPECTIVE SUCCESSORS AND ASSIGNS, AND THEIR RESPECTIVE FORMER AND PRESENT OFFICERS, DIRECTORS, MEMBERS, EMPLOYEES, AGENTS, REPRESENTATIVES, ATTORNEYS, SERVANTS, CONTRACTORS, AND CONSULTANTS (COLLECTIVELY “RELEASEES”) FROM, AND AGREE NOT TO SUE THE RELEASEES WITH RESPECT TO, ANY AND ALL LOSSES, DAMAGES, INJURIES OR EXPENSES, INCLUDING, WITHOUT LIMITATION, BODILY INJURY, DEATH OR PROPERTY DAMAGE, RESULTING FROM OR IN ANY WAY RELATING TO YOUR PARTICIPATION IN THE PROGRAM DUE TO ANY CAUSE WHATSOEVER, INCLUDING, WITHOUT LIMITATION, ANY NEGLIGENCE OR OTHER ACTION OR OMISSION OF ANY RELEASEE OR ANY OTHER PERSON. YOU ALSO AGREE TO INDEMNIFY RELEASEES FROM ANY AND ALL THIRD PARTY CLAIMS CAUSED IN WHOLE OR IN PART BY YOUR ACTIONS.
YOU AGREE THAT THE PROVISIONS OF THIS PARAGRAPH VI (“WAIVER AND RELEASE OF LIABILITY”) ARE LEGALLY BINDING ON YOU, YOUR HEIRS, EXECUTORS, ADMINISTRATORS AND ASSIGNS.
BY SIGNING YOUR INITIALS ON THE LINE BELOW, YOU VERIFY THAT YOU HAVE CAREFULLY READ THIS WAIVER AND RELEASE AND FULLY UNDERSTAND THAT IT IS A WAIVER AND RELEASE OF LIABILITY.
VII. CONFIDENTIALITY OF INFORMATION:
Any information learned from this Program in which you might be identified will be confidential and disclosed only with your permission. By signing this form, however, you allow the AICR dietitians to make your information available to the AICR. If information learned from this Program is published, you will not be identified by name.
If you have any further questions, you can contact Alice Bender, MS, RD at the AICR directly at (202) 328-7744.
- VOLUNTARY PARTICIPATION:
Your participation in the Program is voluntary. You are free to withdraw your consent for participation in the Program without penalty at any time.