Guest Speaker/Co-Host Form

Full Name*

First NameLast Name

Phone Number*

E-mail*

example@example.com

Are You Interested in Becoming a Guest Speaker or Co-Host?*

If Co-Host, What Month Are You Available? (Please note, February is already booked)

If Guest Speaker, What Date Would You Like to Request?

Date

If You're a Guest Speaker, What Will Your Topic of Discussion Be?

Please Provide a Short Social Media Bio for Promotion:*

Please Upload a Headshot You'd Link to Use for Promotion:*

How did you hear about us?*

Without expectation of compensation or other remuneration, now or in the future, I blanks hereby give my consent to [Embrace Your Cake, LLC, Sisters Inspire Sisters, and Monique Denton-Davis], its affiliates and agents, to use my image and likeness and/or any interview statements from me in its publications, advertising, or other media activities (including the internet.)

This consent includes, but is not limited to (initial where applicable):

blank (a) Permission to interview, film, photograph, tape, or otherwise make a video production of me and/or record my voice;

blank (a) Permission to use my name; and

blank (a) Permission to use quotes from the interview(s) (or excerpts of such quotes), the film, photograph(s), tape(s), reproduction(s) of me, and/or recording of my voice, in part or in whole, in its publications, in newspapers, magazines, and other print media, on television, radio, and electronic media (including the internet), in theatrical media and/or in mailings for educational and awareness purposes.

This consent is given in perpetuity and does not require prior approval by me.

First Name   Last Name

Signature

Street Address   Address Line 2   City   State   Zip

Date

Monique Denton-Davis
Founder & CEO
516.304.2446
Port Washington, NY 11050

www.embraceyourcake.com
www.sistersinspiresisters.com

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Guest Speaker/Co-Host Form:

Social Media Release Form