Hack Your Biology - Speaker Intake Form

Hack Your Biology - Speaker Intake Form
Speaker Name:*

First NameLast Name
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number:*
Please enter a valid phone number.Format: (000) 000-0000.
YesNo
Assistant's Name:

First NameLast Name
Assistant's Email:
example@example.com
Brief Bio (Please copy and paste your bio below)*
Please upload your headshot here:*

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What is your approximate email list size? (For tracking and engagement)*
Less then 10%10-20%20-30%30-40%50-60%more then 60%I don't know
The topic you would like to discuss on the interview (please include any discussion points you would like me to cover)*
Title of your offer*
Link to your offer*
Offer Description*
Have you decided on your time slot for the live masterclass? If not, please put 1-2, 30 minute time slots between 10:15 am ET - 12:45 pm ET on April 27th or April 28th that work best for you :*
Promotional Period: April 18th - April 26th

Please let us know your promo dates below:
When will you send your first solo email? (between April 18th - April 26th)*

MonthDayYear
Date
When will you send your newsletter/reminder email? (Between April 18th - April 26th, must be a different date from your solo email)*

MonthDayYear
Date
When will you share on your social media platforms? (Between April 18th - April 26th)*

MonthDayYear
Date
Please provide a link for us to opt-in to your email list (for tracking purposes) and your social media handles below:*
Please read and sign our Speaker Agreement below:
Speaker Release Form for “Hack Your Biology” Interview Series

Stephanie Grosvenor desires to electronically record speaker’s interview via video recording. Guest/Speaker understands that for educational, promotional and commercial applications, Stephanie Grosvenor will make Speaker’s interview video recording available at no charge for attendees of this virtual event.

1. Guest/Speaker hereby grants to Stephanie Grosvenor the right to use his or her name, voice, image, words, participation, and title in whole or in part in these Recordings and/or compilations for any correspondence, publicity, advertising, promotion, or other derivative materials based on them.

2. Guest/Speaker hereby grants Stephanie Grosvenor the unconditional and irrevocable right to reproduce the recording in any format, and to distribute, sell, prepare derivative works, advertise, and publicize the recordings without compensation to Guest Speaker (except entitled affiliate commission detailed in #5 below). Stephanie Grosvenor shall own the worldwide rights, title, and interest, including copyright in, and to, the Guest/Speaker’s Recording. However, Guest/Speaker shall also retain the right to use his or her own Recording for any purpose in future. Guest/Speaker has the full unconditional right to reproduce the recording in any format, and to distribute, sell, prepare derivative works, advertise, and publicize the recording.

3. Guest/Speaker shall be provided with a copy of his or her Recording in electronic format on the day of its release.

4. Guest/Speaker agrees to send the minimum of 1 (one) sole email to their whole database during the agreed-upon promotion period. The Guest/Speaker also agrees to send 1 (one) newsletter blurb and promote on all available social media outlets during the promotion period. Guest/speaker will let Stephanie Grosvenor know ahead of time what dates the promotional material will be sent out.

5. Guest/Speaker is permitted to make a FREE or low ticket item offer during his or her presentation/interview. A URL link to this offer will be sent to Stephanie Grosvenor ahead of time, to be sent out with guest/speakers interview via email.

6. Guest/Speaker represents that he or she has the full right, power and authority to grant this release and to perform all of the provisions thereof.

7. Guest/Speaker agrees to indemnify and hold harmless Stephanie Grosvenor from and against all claims, losses, expenses and liabilities of every kind including reasonable attorney’s fees arising out of the inaccuracy or breach of any provision of this Agreement. Guest/Speaker expressly releases Stephanie Grosvenor from any and all claims arising out of the use of the material.

Please indicate your understanding and agreement with the terms of this release by signing in the space provided below.
I have read and understand this release and have signed on:*

MonthDayYear
Date
Name*

First NameLast Name
Email*
example@example.com
Signature:*
Should be Empty:

Hack Your Biology - Speaker Intake Form

Promotional Period: April 18th - April 26th

Please read and sign our Speaker Agreement below: