The Mindful Rebel Podcast Interview Questionnaire
Your Name as you would like it to appear on the website: *
Preferred gender pronoun: *
A preferred gender pronoun (PGP) is a pronoun an individual chooses to identify with and would prefer others use when talking to or about that individual. For example, She, her, hers, he, him, his, they, etc...
Business/Organization: *
Your Title: *
Email: *
Cell: *
Where can we direct our listeners to get in touch with you? (Your Website?) *
Facebook Page:
We want to promote your episode and YOU as effectively as possible! To that end please provide us with your Logo, headshot, images of you speaking/training, and a photo of you following your passion or doing something you love (candid shots are fine). *
Short bio and current focus: *
If you have a bio already written in a document, you can attach it here:
Some of your key accomplishments you would like to share: *
Links you would like to share to some of your own resources: *
Topics you would like to discuss (around mindfulness, creativity, leadership, entrepreneurship, etc.): *
What is one book, movie, television show, tool or resource that you would recommend to everyone listening right now to help them grow in the coming year? *
Is there anything in the news/media that is interesting to you or that you are passionate about that you would want to discuss or talk about? *
Do you have any specific questions you'd like to be asked during the show? *
Podcast Interview Release:
I hereby grant to Shawn Moore (The Mindful Rebel Podcast), their subsidiaries, affiliates, agents, and successors the right and permission to record, use, publish, stream live, offer for sale, or otherwise distribute any audio or video interview 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 The Mindful Rebel Podcast 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. I understand that I waive any right that I may have to inspect or approve the finished product or any written copy that may be used in connection therewith.

I understand that The Mindful Rebel Podcast has the right to edit and/or transcribe your audio recordings. I understand the recording of this session does NOT constitute a guarantee on the part of The Mindful Rebel Podcast that my session will be published/shared as a podcast. (It is likely it will be published, but not definite).

I understand that I will receive no compensation for appearances on and participation in this specific episode. I understand that name and likeness may be used in advertising and promotional material for this specific episode, but not as an endorsement of any product or service unless agreed upon by both the Guest named above as well as The Mindful Rebel Podcast.

I hereby warrant and represent that I have the right to enter into this agreement and to grant the rights granted to The Mindful Rebel Podcast herein. I agree that during the course of the interview 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 The Mindful Rebel Podcast harmless against any such claims.

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