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Sensory Kit Forms
I checked out this kit for:
(Required)
Myself
My Child
My Parent
Other
Other
(Required)
What items in the kit did you utilize? Select all that apply.
(Required)
Noise-Reducing Headphones
Sunglasses
Handheld Fidget
Liquid Motion Bubbler
Sensory Stones
Cooling Towel
Sensory Brush
Visual Timer
Bubbles
Did you request any additional accommodations for this event? If so, please describe.
During what type of program or event did you use the kit today? Select all that apply.
(Required)
A structured class or program
A community event (seated)
A community event (not specifically seated)
On-site Program (at the Mayerson JCC)
Off-site Program (NOT at the Mayerson JCC)
Fitness Program
Kids Class or Program
Unstructured Visit (not during any specific program or event)
What class/program/event did you attend?
The materials in this kit improved my overall experience of the program.
(Required)
Yes
No
Having this resource/accommodation available made it possible for me to attend this program when I otherwise may not have.
(Required)
Yes
No
The materials in this kit made it possible for me to stay and participate in the class/program longer than I might have without them.
(Required)
Yes
No
Sensory kits and other accessibility features have made it easier for me to join JCC programming. (1 being not at all and 5 being very.)
(Required)
1
2
3
4
5
Requesting these materials, or any other accommodation, was easy. (1 being not at all and 5 being very.)
(Required)
1
2
3
4
5
How likely are you to recommend a sensory kit to someone else? (1 being not at all and 10 being very.)
(Required)
1
2
3
4
5
6
7
8
9
10
Is there anything you feel is missing from the kit or anything else you would like to share about your experience?
Name
First
Last
Phone
Email
