The Endowment for Medical Research
The Protocol for Phase One of the Diabetic Research Initiative Pilot Survey
The Protocol for Phase One of the Diabetic Research Initiative Pilot Survey is very simple. Before projected Clinical Trials are started, we are conducting a very basic self funding Pilot Survey.
We have reason to believe the Chocolate Truffles and Trehalose are beneficial for good health. While we have had some people eat an unbelievably large number of the truffles in a short period of time without their blood sugar increasing (according to their own monitoring), we do not know if that will hold for everyone.
We are mainly interested in gathering data from diabetics who closely monitor their blood sugar. A general health evaluation sheet is also furnished and completion is required.
The Basic Protocol
Each participant of Phase One of the Diabetic Research Initiative Pilot Survey will receive enough chocolate truffles for 3 truffles per day for 4 weeks. He or she will also receive 3 pounds of trehalose and are asked to use 6 Tablespoons full per day as a sweetener instead of their regular table sugar.
We would appreciate a medical diagnosis of the participant if he or she has been declared diabetic.
Careful and often monitoring of the blood sugar level is part of the date required to participate.
A baseline of the blood sugar is required before eating the truffles.
Seven dozen truffles (84) along with the three pounds of trehalose will be shipped at the beginning of the Pilot Survey. This is enough for three truffles per day. HOWEVER, the participants may eat as many truffles at one time as they desire AS LONG AS CLOSE MONITORING OF THE BLOOD SURGAR IS MAINTAINED DURING THE DAY AND RECORDS ARE REPORTS TO US.
While the blood sugar may not spike like it does with other sugars, it may more gradually change and that data is important to gather. What is the blood sugar (a) immediately after eating one or more truffles, and (b) What it the blood sugar level two or three hours later.
Phase One of the Diabetic Research Initiative
with Chocolate Truffles and Trehalose
Benefactor’s Contribution Form for ONE Individual
This is a self funding project. A Benefactor is needed for each Participant in the pilot survey. The participant will receive approximately $300 worth of special chocolate truffles and trehalose and is required to monitor his or her blood sugar on a regular basis. The full amount of $296 is required to enter a Participant in the Four Week Diabetic Research Initiative Pilot Survey. The four week supply of chocolate truffles and trehalose along with the Evaluation Forms will be sent at one time.
Optional heavy metal and toxicity hair kits are available valued at $300 is recommended for an additional contribution of $100. Two kits with scales are send so one hair analysis may be made now with the other analysis made at a later date. This information is good to know as heavy metals may contribute to various symptoms.
I wish to make a donation to The Endowment for Medical Research in the amount listed below to help fund Phase One of the Diabetic Research Initiative with chocolate truffles and trehalose: (Use separate form for each participant.)
$296 ____ Hair Analysis Test Kits $100 for two
Other contribution $______Save $177 for 24 week program at $1,599.
TOTAL AMOUNT$______
Please print Participant’s name:
Should the Participant be unable or unwilling to continue in the Pilot Survey, I understand that there are no refunds for this donation. I further understand that the balance may be transferred to another Participant at The Endowment’s discretion.
I Understand and Agree:
Benefactor’s Signature: Date:
Please Print
Benefactor’s Name:
Street Address:
City: State: Zip:
Phone: Fax:
Additional Phone(s):
E-mail:
DONATION INFORMATION: Amount: $______Check Number:
CREDIT CARD: MC VISA American Express Discover
Name on card (please print): Zip Code for Card:
Signature:
Form Creation Date: September 23, 2006
RELEASE and INDEMNIFICATION FORM
We strongly recommend the Benefactor, Spouse, Legal Guardian,
and/or Participant print a copy of this form for their records.
The individual, as listed below, has my permission to fully participate in The Endowment for Medical Research proposed pilot survey and to participate in all activities associated with the program. I represent that I am lawfully acting in the capacity as the spouse and/or natural or legal guardian of the named individual.
In connection with and in consideration of the individual’s participation in the program, I, on behalf of this individual and myself, my heirs, personal representative(s) and assigns, hereby represent and agree as follows:
1) I am aware that the individual will be participating in a program which includes Nutritional Supplementations, which will be provided through The Endowment for Medical Research, a 501(c)(3) non-profit public charity. I am further aware that the nutritional supplements being provided for use in the program consist of natural ingredients, and an ingredient list has been provided for my review. I have been informed that there are no known side effects from consumption of these food supplements other than such allergic reactions as might result from any listed food contained therein.
2) I understand that the program also includes educational elements regarding elimination of foods that may cause certain symptoms, optional recommended tests such as hair analysis, drinking water, and techniques to help strengthen the mental activity and help build mental confidence.
3) I understand that the individual is not in any way required to participate in the Program, but is able to participate and I consent to his/her participation and completion of the Program.
4) To the fullest extent permitted by law, I hereby release and forever discharge, and agree not to sue and do hereby indemnify and hold harmless The Endowment for Medical Research, its founder, webmaster, coordinators, staff or volunteers from and against any and all liabilities, claims, demands and causes of acting of any kind on account of any loss, damage, illness, or injury to person or property in any way arising out of or relating to participation in the program and/or related activities, whether due to the negligence, mistake, or other action or inaction of The Endowment for Medical Research or any other person or entity.
I CERTIFY THAT I AM AT LEAST 18 YEARS OLD,
THAT I HAVE READ AND FULLY UNDERSTAND THIS RELEASE AND INDEMNIFICATION FORM, AND
I SIGN IT VOLUNTARILY WITH FULL KNOWLEDGE OF ITS SIGNIFICANCE.
......
Print Name of Participating Individual:
______Age
Signature of Participating Individual:
______Date
IF APPLICABLE:
Print Name of Spouse/Legal Guardian Having Care and Custody of Participating Individual:
Signature of Spouse/Legal Guardian Having Care and Custody of Participating Individual:
______Date
Emergency Telephone (_____) ______E-mail Address
Form Creation Date: April 7, 2006
APPLICATION FORM
Please fill in all known and required information on this form. This Application Form MUST be on file.
DATE OF APPLICATION:
Information regarding PARTICIPANT:
First Name: MI Last Name
Street Address:
City: State: Zip:
Applicant resides at above address ______Applicant resides at a Health Care Facility ______
E-mail Address:
Age in years Birth date: Gender (Male/Female)
Height: Feet InchesWeight: Pounds
Has this condition been diagnosed by a doctor? ______Yes ______No
Diagnosis:
Information regarding Spouse:
Name:
If different from above: Address
Primary Telephone Number: Secondary Telephone Number
E-mail Address:
Information regarding LEGAL GUARDIAN:
Name: Relationship to Participant:
If different from above: Address
Primary Telephone Number: Secondary Telephone Number
E-mail Address:
Doctor Information:
Name: Telephone Number:
Is your doctor familiar with Glyconutritients? ______YES ______NO
Benefactor Information if not Spouse or Guardian:
Name: Telephone Number:
Coordinator Information: (Not Required)
Name: Telephone Number:
E-mail:
Form Creation Date: April 7, 2006
P. O. Box 73089 Houston, Texas 77273 • 281-587-2020 • FAX 281-893-6397
• Website:
The Endowment for Medical Research is a 501(c)(3) Non-Profit Faith Based Scientific Research, Educational Public Charity.
Non-Profit Tax ID #54-2073489 • DUNS #140133815 for Medical Research and Education Research