Seniorocity VR Facility Consent

Thank you for your interest in hosting a Seniorocity VR session.

Seniorocity VR works with senior centers, community organizations, residential communities, wellness programs, libraries, and other community-based partners to provide guided immersive experiences for older adults and participants.

This brief form helps us create safe, comfortable, and well-organized experiences for participants, staff, and host organizations.

Our goal is to support welcoming, thoughtful, and community-centered sessions that encourage engagement, exploration, and meaningful connection.

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Facility / Host Location (required) *

Facility Name recorded

Session Date (automatically recorded)

10/05/2026 8:46 PM (Recorded automatically at time of submission)

Participant Name *

(Enter the full name of the participant, even if completed by a representative.)

Health & Comfort Acknowledgment – Please let us know if any of the following apply so we can ensure a comfortable experience:

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

Audio Documentation Consent *

• 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.

Photo / Video / Testimonial Preference – 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 *

• I understand Seniorocity VR 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.

Facility Acknowledgment *

• I understand this session is conducted in coordination with the host facility, and facility staff remain responsible for participant care and emergency response procedures.

Electronic Signature Agreement *

• I have read and agree to this Seniorocity VR Session Consent Form. I understand that checking this box and typing my name below constitutes my electronic signature.

Typed Name / Electronic Signature *

Representative Authorization

• I am authorized to complete this form on behalf of the participant named above.

Date of Agreement is automatically recorded at the time of submission.

Submit

Seniorocity • Partnership • Deployment