Win at Life Podcast Intake Form

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Dear Guest, please fill out this form to better enable us to discuss the topics you want to discuss when you are interviewed in Win at Life Podcast.

Interview calls all required. we won’t except you. If you don’t do one.

If you want specific questions asked please email Danielle at daniellewwow@gmail.com.

Email *

100 Word Bio *

This info is REQUIRED 24 hours prior to your scheduled interview phone call! If we have not received your bio 24 hours prior, your interview will be canceled.

Name *

Cell Phone *

Have any questions for Win at the end of the interview? Four questions are open that you can ask Win. *

Website *

Please listen to the podcast. What episode did you listen to and why it was your favorite? Win won’t contact you until you listen to episode and tell us why is your favorite episode is. *

Is this your first interview? *

Yes

I am comfortable on Radio *

Yes

Other:

I have a disability and need assistance *

Yes

What would you like to discuss during your interview? You may include up to THREE topics or specific questions you would like Win to ask you. *

What is the call to action you would like to announce during the Podcast? *

I will be sharing the podcast links to these social media profiles: *

Please provide links to YOUR social profile urls that you will share the podcast to, so we can connect to and thank you there!

I will be sharing the podcast links to these social media forums/communities/groups: Put "n/a" if none. *

Please list the urls of any Facebook, LinkedIn or other social media groups or communities that you will share the podcast to, so we can connect and thank you there!

Is there anyone you would like to refer to us as a potential guest to be interviewed on the "Win at Life" podcast? Please list their names and email contact or website url below :) *

Thanks for helping us find great guests for the Win at Life podcast! Guests should have some advice for: 1) folks who are interested in blogging, writing, and getting published either through self-publishing or a traditional publishing company, and/or 2) advice for how to mentally and emotionally cope with challenges of mental or physical disabilities while finding their voices in an able-bodied world.

PODCAST RELEASE FORM - 1500 E Wahalla Ln.Phoenix AZ 85024. Podcast Title/Topic: Win at Life / Please sign and submit this form at lease 24 hours BEFORE YOUR INTERVIEW! =======================================This is to confirm that the undersigned has agreed to be interviewed or otherwise participate in Win at Life podcast described above. As a condition of publication/broadcast and for no monetary compensation, we (WAL) request the nonexclusive worldwide rights to reproduce, distribute, and oral and/or video presentation, in whole or in part, in any media, as part of this publication/broadcast published under the auspices of WAL. We shall have the right to edit and/or transcribe your presentation. You also grant the WAL the right to use your name and biography in connection with the presentation. You warrant that your presentation is original with you, that publication/broadcast will not infringe on the rights of others, and that you have full power to grant this license. Should your presentation/broadcast incorporate copyrighted material of others, you warrant that you have obtained such permission from those parties for publication/broadcast by the ABA, consistent with this Agreement.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 the ABA to publish your presentation or other materials.I hereby consent to the use of my oral and/or video presentation as described and agree with the provisions of this release form: Signature: Date:
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