Wellness on Wheels Interest Form

Please fill in your information below and we will contact you within one week!

Group Information

Group Name

Type of Group

Group Size

Primary Contact’s Information



Phone Number:

Event Request (s)

Day, Date and & Time
- List the day, date and time you would like the class(es) to be held.
- Please use one line for each individual class request.
- Please note: First Workshop is free. The group will be charged $15.00 for each following session.

Workshop Request 1:
Workshop Request 2:
Workshop Request 3:
Workshop Request 4:

Instructor Request Options

Do you have an instructor preference?

If you would like to request a specific instructor, please write name here:

Space Reservation Information

Have an on campus space reserved, please complete the following information:
Building Name/Field Space:
Room Number:
If you have requested multiple times and spaces are different for each time please note it here:

Have NOT reserved a space, please reserve an on campus space at least 48 hours prior to your scheduled workshop and notify Jill Harper @ ext 2978 or jharper@esu.edu. Please be sure the space reserved is large enough to accommodate your group.

Additional Comments/Request

Please include any additional information you would like for us to know below.

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