Seniorocity Immersive Engagement Community Participation

Thank you for participating in a Seniorocity Immersive Engagement experience.

Seniorocity Immersive Engagement offers guided immersive experiences designed to encourage curiosity, conversation, engagement, and shared discovery through immersive technology.

This brief form helps us provide a safe, comfortable, and well-supported experience for participants and community members.

Participation is voluntary, and sessions may be paused or stopped at any time. While most participants find the experience enjoyable and engaging, some individuals may experience temporary dizziness, motion sensitivity, or mild discomfort while using immersive technology.

If you have questions before participating, please speak with a facilitator or staff member.

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(required) during Date

Participant Name *

Enter the full name of the participant.

Phone

Email

Session Location

Emergency Contact

(Recommended for community sessions if not accompanied by staff or family.)

Relationship

(optional)

Health & Comfort – Please let us know if any of the following apply so we can ensure a comfortable experience. You may also leave this blank or discuss privately.

• Balance concerns
• Motion sensitivity / vertigo
• Vision or hearing limitations
• Prefer to discuss privately
• None of the above

Audio Documentation Consent (required) *

• I understand and consent to limited audio note-taking and facilitator documentation during the session for program improvement, training, and impact reporting. These recordings are not used publicly without additional permission.

Media Preference (required) – Please select your preference for any photos or video taken during the session: *

• No public media use
• Image only, no name
• First name only
• Full name, image, and testimonial

Liability Waiver (required) *

• I understand Seniorocity Immersive Engagement is a guided engagement experience and not medical care. I voluntarily participate and accept the risks of temporary discomfort, dizziness, fatigue, or emotional reactions. I release American Family Center, Inc., NuVistas VR, Mynd Immersive, and participating partners from liability, except in cases of gross negligence or willful misconduct.

Participant Responsibility Acknowledgment (required) *

• I understand that I am participating independently and may stop at any time. If I experience discomfort, I will notify the facilitator.

Electronic Signature Agreement *

• I have read and agree to this Seniorocity Immersive Engagement Session Consent Form, including the participation acknowledgment, audio documentation consent, media preferences, and liability waiver. I understand that checking this box and typing my name below constitutes my electronic signature.

Typed Name / Electronic Signature *

Date of Agreement (automatically recorded)

Submit

Seniorocity • Partnership • Deployment