Parent Consent Form

Weighted Capes Use Consent & Liability Waiver

Child's Full Name: ____________________________________
 Parent/Guardian Name: _______________________________
 Date: ______________________

Purpose of Weighted capes:

We occasionally use capes to provide calming sensory input for children during haircut services. These tools are commonly used to support regulation and comfort, especially in children with sensory sensitivities.

Important Notes:

  • Weighted items are not medical devices and are not being used as a form of therapy.

  • These items will never be forced on a child, and can be removed at any time upon request.

  • We observe all children closely during use and ensure weights are used within recommended limits (typically under 10% of body weight).

  • Use is always optional and based on the child’s comfort and tolerance.

 

 

Parent/Guardian Consent & Acknowledgment:

By signing below, I understand and agree that:

  • I give permission for [Business Name] to offer my child the use of weighted sensory items during their time at the facility.

  • I understand that this is not a substitute for occupational therapy or medical advice.

  • I acknowledge that I have informed staff of any relevant medical or developmental conditions (e.g., respiratory issues, low muscle tone, circulatory disorders, seizure disorders, etc.) that may make the use of weighted items unsafe for my child.

  • I release [Business Name] and its staff from any liability for unintended outcomes related to the voluntary use of weighted items.

Signature of Parent/Guardian: ___________________________
 Date: ______________________

Emergency Contact Name & Number: ______________________

 

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