Please print this form, and when completed mail it and/or your contribution to:
Institute
of Nutrition Education and Research
1601 N. Sepulveda
Blvd., Ste 342
Manhattan Beach, California 90266
Tel/Fax: (310) 374-3733
Yes, I want to participate in the Vegan Health Study.
My diet is currently completely vegan: Yes ____ No ____
If yes, how long? ____ years ____ months
My diet was vegan in the past, but is not vegan now: ____ Vegan from _______ to _______
My diet is: Lacto-vegetarian ____ Ovo-vegetarian ____ Lacto/ovo vegetarian ____ Other ____
My diet has never been vegan and I would be willing to serve as an "omnivore control": _____
Name: __________________________________________________________________
Address: ________________________________________________________________
City: ________________________________ State: __________ Zip Code: ___________
Telephone: ( _____ ) _____________ e-mail: ______________________________
Sex: M_____ F_____ Age: ________
Signature ____________________________________________ Date: ________________
I know of another person (or people) who might be interested in participating in the Study:
Name: __________________________________________________________________
Address: ________________________________________________________________
City: ________________________________ State: __________ Zip Code: ___________
Telephone: ( _____ ) _____________ e-mail: ______________________________
The study is sponsored by the not-for-profit, 501 (c)(3) Institute of Nutrition Education and Research. All donations to help support this research are tax-deductible to the fullest extent of the law and will be greatly appreciated. Please make checks payable to "Vegan Health Study."
Mail to:
Institute of Nutrition
Education and Research
1601 N. Sepulveda
Blvd., Ste 342
Manhattan Beach, California 90266
Tel/Fax: (310) 374-3733