Wellness Haven Nutrition Program Registration Form

Welcome to Wellness Haven Nutrition Program - Lower Your Fat Percentage
We applaud you in making this very powerful decision in having this intense desire to get into a healthy lifestyle with improved cooking and eating habits.We appreciate your patience in filling your information so that we can get you started off as smoothly as possible, for we are serious about your health. All details of the program are available at: http://wellnesshaven.yourcoachsite.com/lower-your-fat-percentage/
There is a paypal button for easy and secure payments

What attracted you to Wellness Haven Nutrition Program and how did you hear about it? In your own words let us know what are you hoping to achieve with the nutrition program. (required)

Before we can get you started into our 12 week program, there are a few house-keeping items we need to take care of. Please read Wellness Haven Policies and declarations thoroughly so that there are no confusions left before you buy any of our product and services .and answer the questions as you go along. Our policies and declarations regarding Wellness Haven Nutrition Program is as follows:

A. Please understand that Umang is not a nutritionist or a medical doctor. She is a Wellness Coach and an Experienced Certified Yoga Instructor guiding those who want to get started on the wellness track through Yoga, Controlled Breathing, Meditation, Nutrition, and Accountability in various areas of their life. Umang's intense desire to learn about what it takes to be healthy nutritionally led her into researching various nutrition programs. What she found was that the nutrition programs invariably wanted her to take outside supplements to melt fat and/or provide their own food. Not wanting to be dependent on any outside source for the rest of her life, she created her own path to nutrition and wellness as she researched through programs. First she applied it to her daughter and herself and the results were simply magical. That is when she decided to start coaching others as well so that others could enjoy similar results. There have been amazing results with her yoga students and those who were not her yoga students as a result of going through her 12 week Nutrition program. Testimonials can be viewed at: http://wellnesshaven.yourcoachsite.com/lower-your-fat-percentage/
Wellness Haven website: http://wellnesshaven.yourcoachsite.com/
Wellness Haven Policies: http://wellnesshaven.yourcoachsite.com/policies/
(required)

B. Please make sure that you have checked with your doctor before you begin any changes in your health. We hold you responsible for making your health decision with Wellness Haven, free of any outside force. (required)

C. Please make sure that Umang's email addresses umanggoel2002@yahoo.com and umang@wellnesshaven.com do not end up in your SPAM. We make sure that we get back to you on this form submission as well as confirm your initial consultation/evaluation appointment within 24 -48 hours. If you do not hear directly from Umang with a confirmation, please send her an email and call her at: (925)819-6327

D. Please be aware that even though our success rate is very high, and our students make a change in their body fat percentage as well as lower their weight, metabolism is very unique to each individual. Some people take all of 12 weeks to see results while others start seeing amazing results in the first week itself. Invariably people feel lighter, and start fitting in clothes as a result of becoming leaner. But we do not guarantee that your results will be the same as another individual. We also expect you to follow our advice whether it is difficult or not for you in order to see results. We expect you to exercise, eat according to our plan as well as begin the program with a positive attitude, open mindedness and faith that you will improve your lifestyle. We expect you to understand that Wellness Haven or Umang cannot guarantee results; that you need to follow the advice given thoroughly making sure that you are clear about what is being advised; that you need to exercise regularly, and not exercising will be a decision that you will need to make for yourself and will not hold Wellness Haven or Umang responsible for not seeing the results.

E. Payment is needed upfront BEFORE you begin the Nutrition program and after making sure that you understand thoroughly what is involved in the program. Once payment is made it cannot be refunded under any condition for we expect you to understand the needs of the program before you jump into the program.

E. Please understand that you will be required to invest in a Fat Percentage Scale that you will buy on your own either online or at a local store, if you are not a local student, in which case we still highly recommend that you get one. This fat percentage scale does not need to be a fancy equipment. It should be able to take your gender, age and whether you are an adult or a child, and spit out your body weight and fat percentage.

F. Please understand that you will be required to measure yourself in the following areas:
Record Initial Data:

Recording Time:

Age:

Height:

Whole Body Weight:

Body Fat Percentage:

Bust-line (Women or NA):

Chest (men or NA):

Upper Arm:

Waist:

Hip:

Thigh:

Calf:

Dress Size:

(required)

Please note that results will vary based upon your own commitment. Let us know how committed you are in your own words. (required)


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 issues? (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 physical or mental issues, have you consulted your doctor for doing the nutrition program? Please consult your doctor before you sign up for the nutrition program. If you do not you are held completely responsible for making the decision to join our program. (required)

Initial Consultation is FREE. Please schedule a phone consultation if you are remote and a consultation at the Wellness Haven Yoga Studio if you are local. Please let us know your desired date/time for consultation although we will get contact you confirming or re-scheduling an appropriate date/time suitable to both of us. (required)


Emergency Contact Info for your own safety

Emergency Contact Name (required)

Relationship (required)

Phone# (required)

Release of Liability:

In signing below I agree that Wellness Haven LLC, the Instructor & the Facility are in no way responsible for my decision to get into the Wellness Haven Nutrition Program. I understand that Umang is not a nutritionist or a medical doctor. I understand that the program may prove to be difficult to handle. I understand that if I decide to quit the program for any reason, I will not be able to get a refund for any reason. Whether I decide to consult my own doctor or not is completely my decision and with this knowledge I am enrolling into the Wellness Haven Nutrition Program. I understand that Wellness haven reserves the right to refuse service for any reason. 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.

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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

  • 5:30 am - Rehab Yoga By Appointment Only
  • 9:00 am - Mat Yoga - Multi Level
  • 10:00 am - Mat Yoga - Multi Level
  • 11:00 am - Chair Yoga
  • 1:00 pm - Consultation, Evaluation, Nutrition Session, Private Session
Umang's Wellness Haven