Rise Sensory Space Policy - My Guy and I Dance 2025
Provided at no additional cost by the staff and volunteers of Rise Therapy & Wellness - Richland, MI.
Objective:
Promote inclusive programming:To support individuals with sensory processing difficulties or overwhelmed by large crowds or loud environments by offering a safe, calming environment.To promote relaxation, self-regulation, and reduce stressTo reset the nervous system and return to the dance and other activitiesPromotes activity toleranceImproves general awareness of self, peers, and the environment
Scope:
The policy applies to the sensory space for the My Guy and I Dance at Gull Lake High School on Saturday, November 8, 2025.
Procedure: Rise Sensory Space Policies
Rise occupational therapy and support staff will be onsiteCheck-in with an adult requiredA signed consent form and liability waiver must be completed prior entry of sensory space.Capacity is approximately 10 individuals at a timeTime limit of 15-20 minutes per sessionMust remove shoes before entering the sensory spaceHand sanitizer is encouraged before entering the sensory spaceCalming sensory items and activities will be available for use inside the sensory space.The sensory space and items are sanitized by staff between users Examples of items located in the sensory area include:Bean bag chair, wiggle seat, flexible seatingCrash padGymnastics matsWeighted items: blanket, vest, stuffed animals, lap padSensory motor movement items: therapy balls, thera-band, weighted ballsRelaxing lighting/star lighting, videos, and musicObjects for mindfulnessFidgets, sensory toolsCalming activities and reading materials
General Precautions
Allergies, seizure history, diagnostic consideration, trauma history,Respiratory precautions, cardiac precautionsMedication changes and or side-effects, environmental (lighting, background noise, tone of voice)
Acknowledgement
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I acknowledge there are some inherent risks associated with the use of therapy equipment that cannot be eliminated regardless of the care taken to avoid injuries from, but not limited to, falling, malfunctioning equipment, skin irritation/rash/bruising from use of treatment agents, sensory equipment, and other occupational therapy items. I understand the risks and I assert that my participation is voluntary and I knowingly assume such risks without holding Rise Therapy & Wellness, its employees, independent contractors, agent, legal representatives, or students accountable for any losses, injuries, or other damages occurring to myself/the client. I further understand I am fully responsible for my own safety. I am the client, parent, or legal guardian/representative and have the legal authority to provide consent.
Testimonial, Photo, and Social Media Consent
I hereby grant Rise Therapy & Wellness and its employees, independent contractors, legal representatives, agents, and students the absolute right and unrestricted permission to use and distribute my testimonial (verbal, written) or any part of my testimonial, photos, and videos. I am an employee or legal guardian/representative and have the legal authority to provide consent for observation.
I understand my confidential rights will be protected under HIPAA.
I authorize Rise Therapy & Wellness to copy, exhibit, publish, or distribute my testimonial, and to photograph and video record for purposes of educational publications, teaching, marketing, publicizing Rise Therapy & Wellness' services, or for any other lawful purpose. My testimonial may be used in printed publications, multimedia presentations, on websites, or in any other distribution media, such as brochures. I waive the right to any royalties or compensation arising from or related to the use of my testimonial, photos, or videos. I understand my confidential rights will be protected under the Health Insurance Portability and Accountability Act (HIPAA). I hold harmless and release Rise Therapy & Wellness, its employees, independent contractors, legal representatives, agents, and students from all claims, demands, and causes of action which I have or may have by reason of this authorization. I am an employee and have the legal authority to provide consent for observation.
Right to revoke release
I acknowledge that I have the right to revoke this release at any time by giving Rise Therapy & Wellness verbal or written notice to:Rise Therapy & Wellness, 8599 N 32nd St Ste 104, Richland,, MI 49083
Caregiver's Name
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First Name
Last Name
Relationship to child(ren)
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Phone Number
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Please enter a valid phone number.
Signature
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Caregiver's 2 Name
First Name
Last Name
Relationship to child(ren)
Phone Number
Please enter a valid phone number.
Signature
Child's Name
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First Name
Last Name
Child's Name
First Name
Last Name
Child's Name
First Name
Last Name
Child's Name
First Name
Last Name
Thank you!
We are looking forward to meeting your sensory needs! Please contact our office if you have any questions at connect@risetherapyandwellness.org or 1-269-203-7394.
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