New Student Form Walnut Creek

New Student Online Registration Form

Welcome to Wellness Haven Community. We appreciate your patience in filling your information so that we can get you started off as smoothly as possible.

So that our communication emails do not end up in your SPAM folder, please add Umang's emails in your secure list, "umanggoel2002@yahoo.com" as well as "umang@wellnesshaven.com." If you have not heard from her, her email maybe in your SPAM folder. We make sure that we get back to you on this form submission as well as confirm your evaluation appointment within 24-48 hours. If you do not hear directly from us with a confirmation, please call us at (925) 819-6327.


Contact Information

First name (required)

Last Name (required)

Gender and Adult or Child (required)

Address (required)

City (required)

State (required)

Zip Code (required)

Email (required)

At least 1 phone number required

Cell Phone (required)

Home Phone (required if different from cell)

Work Phone

Birth Date, to help us understand your needs (required)

Occupation, to help us understand your stress (required)


Health Information

How often do you exercise? 5-7 days a week/ 4-5 days a week/ 3-4 days a week/ 2-3 days a week/ 1-2 days a week/ 1 day a week/ None (required)

What type of exercise do you do? Yoga, Pilates, Aerobics, Dancing, Zumba, Weight-lifting, Running/Jogging/ Walking/ NA (required)

Where do you exercise? 1. At a Gym - Name of the Gym 2. At a Yoga Studio - Name of the Yoga Studio 3. At Home on my own 4. At Home with a DVD 5. NA - I do not exercise (required)

Are you regular with your annual health checkups - Yes or No? (required)

When was your last physical? (required)

Are you facing any physical injury? "Ankle" "Knee" "Lower Back" "Neck" "Shoulder" "Hips" "Wrist" "Other" "None" (required)

Are you facing Mental Stress and/or Depression?(required)

If you are facing Mental Stress and/or Depression, what is the severity? (required)

If you are facing Mental Stress and/or Depression, what is the reason? (required)

If you are facing Mental Stress and/or Depression, would you like to elaborate on the reason? (required)

If other health issues, please describe them or NA

If you are facing injury or other physical or mental issues, have you consulted your doctor for doing yoga and/or meditation and breathing techniques? Please note that if you are in pain but have been doctor recommended to do yoga, our Yoga Basic Stretch is the class to be in, but if you need personal attention, you need private one on one Yoga Therapy, that we also offer, and not a group class. Our Beginner Yoga All Levels class is for those who can handle a flow based class. Please do consult your doctor if you are in any kind of pain or are facing injury before you sign up for a class. (required)


Voucher Info for students coming through external offerings (only if applicable)

Type of Voucher (Name of the company bought from):(required)

Voucher #:(required)

The name the voucher was bought under:(required)

The number below the barcode, if there is one:(required)

Pin code, if there is one:(required)

Number/Type of classes bought:(required)


If you are already familiar with Yoga, what type of classes do you like? List one or all:
1. Slow paced 2. Fast paced 3. Mixture of Slow and Fast paced 4. Flow Style 5. Holding Poses 6. Mixture of Flow and Holding Poses 7. All the above 8. I am not familiar with yoga (required)



Many different health programs are offered at Wellness Haven in San Ramon. If you are interested, please check our website for all details: www.wellnesshaven.com

A. Yoga:

B. Meditation and Breathing

C. 12 Week Nutrition Program - Lower Your Fat Percentage

D. Private Yoga Coaching

E. Private Life or Business Coaching

F. Yoga Retreat

G. Yoga Teacher Training

If you are interested in any of our programs in San Ramon, please let us know:


What are you hoping to achieve at Wellness Haven? Please list the conditions you may be facing. Through our various programs listed above, we offer relief from: Bad Posture, Stress, Anxiety, Depression, Headaches and Migraines, Sleeplessness, Lower Back Pain, Shoulder and Neck Pain, Sciatica, Hormonal issues, Thyroid issues, Arthritic Conditions, High Blood Pressure, High Body Fat, High Cholesterol, High Sugar Level,Tight Muscles, Acidity, and many other physiological problems. Always ask your doctor first. (required)


Emergency Contact Info for your own safety

Emergency Contact Name (required)

Relationship (required)

Phone# (required)

Do you consent to get yourself photographed/video taped in group pictures that we post on our website?


Release of Liability:

In signing below I agree that Wellness Haven LLC, the Instructor & the Facility are in no way responsible for the safekeeping of my personal belongings while I attend class. I understand that the yoga class conducted at Wellness Haven, LLC may be physically strenuous and I voluntarily participate in them with full knowledge that there is risk of personal injury or death. I understand that participating in the wellness Haven Programs - Yoga, Nutrition, Meditation and Breathing, Private Coaching at Wellness Haven, LLC is my own decision and that results vary between individuals. I have read, understood and agree with the Wellness Haven Policies. I agree that neither I, my heirs, assigns or legal representatives will sue or make any other claims of any kind whatsoever against Wellness Haven, LLC, the Instructor & the Facility for any personal injury, property damage/loss, or wrongful death, whether caused by negligence or otherwise.

Please read the above and sign below with your full name and the date:

***Please check your Spam if you do not receive a response from us.
***We reserve the right to refuse service for any reason
***All classes at Wellness Haven are non-refundable. The classes are also non-transferable, which means that classes cannot be shared between 2 people and/or you cannot apply the funds applied towards one program to another.

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Address

Wellness Haven Yoga

110 Ryan Industrial Ct., #14
San Ramon, California 94583
Tel: (925) 819-6327 Email:umang@wellnesshaven.com

Today’s Classes

  • 8:00 am - Chair Yoga
  • 9:00 am - Mat Yoga - Multi Level
  • 11:00 am - Consultation, Evaluation, Nutrition Session, Private Session
Umang's Wellness Haven