Sensory Courtyard Registration and Agreement

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Welcome! In order to keep a valid record of who is using the the Sensory Courtyard, have a record of agreement to terms and conditions and an understanding of the age groups served, please complete the following by checking all that apply and filling in the blanks before your visit. Thank You!

Email *

What is your position/relationship to the Participants *

Regular Education Teacher

Special Education Teacher

Early Childhood Teacher

Occupational Therapist

Physical Therapist

Speech Language Pathologist

Parent

Grandparent

Residential Assistant

Other:

School or Agency *

Number of Participants *

Ages of Participants *

0-3 Years

4-5 Years

6-10 Years

11-14 Years

15--18 Years

19-21 Years

22-39 Years

40-64 Years

65+ Years

Required

Do Participants have *

An Individual Family Service Plan (IFSP)

An Individualized Educational Program

An Independent Living Plan

Required

If so please specify

Autism

Behavioral Disorder (BD)

Deaf Blindness (DB)

Hearing Impairment (HI) Deaf (Severe Profound)

Hearing Impairment (HI) Hard of Hearing (Mild/Moderate)

Mental Handicap

Multiple Impairments (MULTI)

Orthopedic Impairment

Other Health Impairment (OHI)

Specific Learning Disability (SLD)

Speech Language Impairment (SLI) Language

Speech Language Impairment (SLI) Articulation

Speech Language Impairment (SLI) Voice

Speech Language Impairment (SLI) Fluency

Traumatic Brain Injury (TBI)

Visual Impairment (VI) Blind

Visual Impairment (VI) Legally Blind

Visual Impairment (VI) Partially Sighted

Developmental Delay

Other:

Purpose of using the Courtyard *

Educational

Therapeutic

Behavior Modification

Motivational

Other:

Required

***WARNING*** FOR THOSE USING THE SENSORY COURTYARD'S SNOEZELEN ROOM

SOME OF THE LIGHTING AND PROJECTION EQUIPMENT COULD INDUCE SEIZURES IN SOME INDIVIDUALS. PLEASE MONITOR THOSE WITH THE SEIZURE DISORDERS AND ADJUST LIGHTING /EQUIPMENT AS NEEDED.

TERMS AND CONDITION FOR USE OF SENSORY COURTYARD

THE SENSORY COURTYARD IS NOT A PUBLIC PLAYGROUND. IT IS INTENDED TO BE USED AS AN EDUCATIONAL FACILITY.
///*** ADULT SUPERVISION IS REQUIRED AT ALL TIMES***///
ITEMS IN THE COURTYARD MUST BE USED PROPERLY. PLEASE READ ALL SIGNS POSTED FOR RULES AND USE OF AREA BEFORE UTILIZING. AS YOU BEGIN YOUR VISIT TO THE COURTYARD, IF YOU NOTICE ANYTHING NOT WORKING PROPERLY OR DAMAGED, OR IF YOU NEED ASSISTANCE RUNNING ANY OF THE EQUIPMENT, PLEASE NOTIFY OUR OFFICE AT 402-727-3134.
IF SOMETHING BECOMES DAMAGED DURING YOUR STAY, PLEASE CONTACT US IMMEDIATELY AT THE NUMBER LISTED ABOVE.

________________________________________________________________________________________________

WE WANT EVERYONE WHO VISITS THE SENSORY COURTYARD TO HAVE A POSITIVE EXPERIENCE IN A CLEAN AND SAFE ENVIRONMENT. IN ORDER TO ENSURE THIS EXPERIENCE IS AVAILABLE FOR MANY YEARS TO COME, WE ASK THAT YOU LEAVE THE AREAS THE WAY YOU FIND THEM. REPORTANY PROBLEM OR MALFUNCTIONS AS SOON AS POSSIBLE AND BE RESPONSIBLE FOR THE ACTIONS OF THOSE UNDER YOUR SUPERVISION, AS YOU MAY BE HELD ACCOUNTABLE FOR ANY DAMAMGE INCURRED DURING YOUR VISIT.

PLEASE ACKNOWLEDGE AND SUBMIT *

I UNDERSTAND THE WARNING AND TERMS AND CONDITION AND AGREE TO ABIDE BE THE SENSORY COURTYARD.

Required

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