EM's Mold Tour Guest Application

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Hello and thank you for your interest in joining Exposing Mold's first official, "CFS History Mold Tour," set to take place in Truckee, California, hosted by Exposing Mold's Erik Johnson, Kealy Severson, and Alicia Swamy.

The Mold Tour has been designed to educate the public on how toxic mold served as the basis for Chronic Fatigue Syndrome. Erik Johnson will lead the tour, which includes traveling to multiple sites in the Lake Tahoe region to provide an understanding of the environmental changes that occurred during the mystery illness.

During the tour, Exposing Mold's production team will film a docuseries that will be used for research and educational purposes. All guests on this tour will be in the film. However, two guests will be "featured" in the film. Their feature will include close documentation and extensive interviews.

Once this form is complete below, we will be in touch. Spots are filling up fast so please do fill out and submit this as soon as possible. Thanks again!

Note: Incomplete applications will not be considered.

Contact Information: Please include your Full Name, Address, Email, and Phone Number *

Video Consent and Release: Without expectation of compensation or other remuneration, now or in the future, I hereby give my consent to Exposing Mold Inc., 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: (check where applicable) *

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

(b) Permission to use my name; and

(c) Permission to use quotes from the interview(s) (or excerpts of such quotes), the film, photograph(s), tape(s) or 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.

(d) This consent is given in perpetuity, and does not require prior approval by me.

(e) Must be willing to sign an official consent form if chosen to participate in the tour

(f) Must be willing to sign release of liability for California and Nevada

Other:

Required

Reason(s) for wanting to join the Mold Tour: *

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