Everledger Pre VR Survey

Please answer these questions before participating in the VR workshop.

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* 1. First Name

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* 2. Surname

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* 3. Job Title / Role

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* 4. Email Address

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* 5. To participate in the VR / video you must agree to the following waiver. If you would not like to participate, or would prefer the 2 dimensional version please alert Leanne prior to the workshop.

- The 360 degree video lasts 6 minutes and includes uncomfortable sounds, sights, touch and maybe scents.
- Participation is completely voluntary and is not recommended for those with a history of psychotic mental illness symptoms.
- You are not obliged to complete the VR simulation. If you would like to stop at any time, please do so by carefully removing the VR headset and earphones.
- You agree and acknowledge that You will not use or access the video if You are pregnant, elderly, have pre-existing binocular vision abnormalities or psychiatric disorders, or suffer from a heart condition or other serious medical condition.
- You agree to indemnify Us, and to hold Us free and harmless from any and all claims, remedies or entitlements against Us for any form of loss, liability, damages, expenses, costs, injury or harm suffered or incurred, arising directly or indirectly from Your acts under this agreement.

Please confirm you agree to the VR waiver.

Yes

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* 6. I hereby grant permission to LOSE YOUR MIND to use photographs and/or video of me taken during workshops in publications, news releases, online, and in other communications related to the mission of LOSE YOUR MIND. (If no, please inform Leanne prior to your session).

Yes

No

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* 7. Please confirm you give permission for LOSE YOUR MIND to contact you via email to seek feedback.

Yes

No