Guest Intake Form
Please take 5-10 minutes to complete this form. It will help me prepare for our conversation and create a stronger show.
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Legal Release
IF YOU AGREE WITH THE FOLLOWING, PLEASE TYPE YOUR FULL NAME AND THE DATE BELOW: I irrevocably consent to the recording and distribution of reproduction(s) of my voice and performance as part of the media program entitled Department 12: An I-O Psych Podcast (herein referred to as the "Program").I acknowledge that Benjamin Butina and Loyalhanna Consulting, LLC (“Podcaster”) is the sole owner of all rights in and to the Program, and the recording(s) thereof, as “works made for hire” pursuant to 17 USC §101, et.seq., for all purposes; and that Podcaster has the unfettered right, among other things, to use, exploit and distribute the Program, and Guest’s performance as embodied therein in any and all media or formats, throughout the world, in perpetuity. Any materials relating to the production and distribution of the Program (“Materials”) become property of Podcaster, and Podcaster shall have the sole and exclusive right to use, exploit and distribute such Materials, throughout the world, in perpetuity. Nothing contained in this Podcast Guest Release shall be construed to obligate Podcaster to use or exploit any of the rights granted or acquired by Podcaster, or to make, sell, license, distribute or otherwise exploit the Program or Materials whatsoever. I understand and agree that I shall receive no compensation for appearances on and participation in the Program. My name and likeness may be used in advertising and promotional material for the Program, but not as an endorsement of any product or service. I hereby release and discharge Podcaster from any and all liability arising out of or in connection with the making, producing, reproducing, processing, exhibiting, distributing, publishing, transmitting by any means or otherwise using the above-mentioned production. *
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