Podcast Guest Form
Name
*
First Name
Last Name
Pronouns
*
She/her
Him/he
Them/They
Other
Please write the phonetic pronunciation of your full name
*
Date of Birth
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Month
-
Day
Year
Date
Additional Names of Guest(s) to appear from this organization (please list full names and dates of birth for each):
Organization
Phone Number
*
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Area Code
Phone Number
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
E-mail
*
example@example.com
Personal Website
Snapchat/Instagram
Why do you want to be on the our podcast channel?
*
Topics you want to discuss
*
Please share any links to past speaking engagements
Please provide a high-resolution headshot to utilize in the podcast promotional materials
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How did you hear about us?
Google Search
Referred by someone
I'm a listener
Anything you want to add?
Please verify that you are human
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I certify that all that is above is true. I am the parent, guardian of or authorized representative for the above named individual(s)/ group. S/he/they has/have my permission to appear physically and/or remotely on the Teens in the D Show without compensation. I hereby grant to Teens in the D Show/Teens in the D Broadcast Media Group, LLC Podcast their subsidiaries, affiliates, agents, successors, and assigns the right and permission to record, use, publish, stream live, offer for sale, or otherwise distribute any audio or video interview and/or session with me. Such right and permission includes, but is not limited to, my name, recorded voice or video, photograph or likeness, biographical information, handouts or any material based upon or derived therefrom. I understand that Teens in the D Show may, at its sole discretion, produce presentations or publications based in whole or in part upon audio interview (or any portions thereof) and/or a video or audio recordings or photographs of said interview, and that such media or transcripts may appear in print, online, or in any manner or media, including but not limited to promoting the podcast or streaming audio program. Teens in the D Show shall have the right to edit and/or transcribe your session and/or interview. I have no right of approval, no claim for compensation, and no claim (including, without limitation, claims based upon defamation) arising out of or in connection with, any use, alteration, or use in any composite form hereunder. I hereby release and discharge Teens in the D Show together with all principals, shareholders, officers, employees, agents, successors, heirs, assigns and affiliates from any and all liability arising out of or in connection with the program, the session, the making, producing, reproducing, processing, exhibiting, distributing, publishing, transmitting by any means or otherwise using the above mentioned production. I hereby warrant and represent that I have the right to enter into this agreement and to grant the rights granted to Teens in the D Show/Teens in the D Broadcast Media Group, LLC herein. I agree that during the course of the interview and/or session I have not violated the rights of any third parties, including but not limited to copyrights, rights of privacy, trade secrets, and non-disclosure agreements, and that in the event of any breach of any of these warranties, that I will defend and hold Teens in the D Show and all affiliates harmless against any such claims. This release shall be binding upon me and my heirs, legal representatives, and assigns. If the foregoing terms are satisfactory, please sign and date this agreement below and return it to the program coordinator. Execution of this Agreement does not obligate Teens in the D Show to broadcast or publish your session or other materials. AGREED AND ACCEPTED by Guest: Your Name: ___________________________________________________________ Agreed by Program Coordinator,Teens in the D Show, Interim Executive Director: Barbara Kellom Signature of person(18years or older) authorized to enter into this agreement on behalf of the guest(s) named above
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Date of Signed Agreement
*
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Month
-
Day
Year
Date
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