Show Host - Black Mental Health Matters

Show Host Application Form

Thank you for your interest in being a host on our Black Mental Health Matters Show. Please fill out this form and we'll reach out to you via email if we think you'd be great host for our show

First Name

Last Name

Professional Title (e.g Licensed Clinical Psychologist)

Please provide a high-resolution headshot. We'll be using the image for promoting your episode.

phone

Street Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code

country

Your Brief Bio(max 3 to 4 lines)

upload your resume

Why do you want to volunteer as a Host?

Availability

Preferred Social Media URL

Website

Which topics or areas in Mental Health are you comfortable hosting shows on?

Is there any product or service you would like to promote during the show?

Yes No

If Yes ,enter details here

Are you happy to share the stream with your audience when it airs? We'd love your support to get your episode out to as many people as possible!

• Media/Audio/Video release

I hereby voluntarily and without compensation authorize voice recording(s) to be made of me. I hereby give permission to Black Mental Health Matters Inc to use, reproduce, and distribute the voice or video recordings, including my name and submitted photo(s). I hereby agree to release Black Mental Health Matters Inc from any claims, damages or liability arising out of such use or distribution. I understand that the use of my name, likeness, and voice or video recordings will be primarily for the purposes of commercial use, education and/or promotion by this organization. I have read and understand the foregoing and I consent to the use of my picture and/or voice or video as specified for the above-described purpose(s). I further understand that no royalty, fee or other compensation of any character shall become payable to me. • Consent - Media Release* I agree to the above media/audio /video release. Consent - Privacy* I understand that personal information collected will not be shared to any third parties and will used solely to advance the organization objectives. I grant Black Mental Health Matters Inc permission to collect and store my data as per its Privacy Policy

black mental health matters

Show Host Application Form

Thank you for your interest in being a host on our Black Mental Health Matters Show. Please fill out this form and we'll reach out to you via email if we think you'd be great host for our show