Interview Intake Form

Complete this form and we will contact you to schedule the interview. After completing this form, you will be directed to fill out Photo and Video Release Form. Interviews are virtual unless you are local to Atlanta and would like an in-person interview.

Name(Required)

First Last

Parent's Name

First Last

Age if Under 18

Phone(Required)

Email(Required)

Address(Required)

City State / Province / Region

City and State Only

Website

Social Media Link

1st Available Date(Required)

Time (EST)(Required)

2nd Available Date

Time (EST)(Required)

3rd Available Date(Required)

Time (EST)(Required)

Upload image for promotions.(Required)

Accepted file types: jpg, heic, png, gif, pdf, jpeg, Max. file size: 2 GB.

Image will be used on social media and website to promote interview.

I am local to Atlanta, GA or I will be in Atlanta, GA and I would like an in-person interview.

Yes

Interview Reminder(Required)

Text Message

Both

None

Acknowledgement(Required)

I agree.

By checking this box, I understand that a parent or guardian must be present for the interview if under the age of 18 years old. The parent or guardian must present themselves on video to confirm presence however they will not be present in the final edit. I also agree to keep answers kid friendly for the entire interview.

Photograph & Video Release Form(Required)

I hereby grant permission to the rights of my image, likeness and sound of my voice as recorded on audio or video tape without payment or any other consideration. I understand that my image may be edited, copied, exhibited, published or distributed and waive the right to inspect or approve the finished product wherein my likeness appears. Additionally, I waive any right to royalties or other compensation arising or related to the use of my image or recording. I also understand that this material may be used in diverse educational settings within an unrestricted geographic area. Photographic, audio or video recordings may be used for the following purposes: • conference presentations • educational presentations or courses • informational presentations • on-line educational courses • educational videos By signing this release I understand this permission signifies that photographic or video recordings of me may be electronically displayed via the Internet or in the public educational setting. I will be consulted about the use of the photographs or video recording for any purpose other than those listed above. There is no time limit on the validity of this release nor is there any geographic limitation on where these materials may be distributed. This release applies to photographic, audio or video recordings collected as part of the sessions listed on this document only. By signing this form I acknowledge that I have completely read and fully understand the above release and agree to be bound thereby. I hereby release any and all claims against any person or organization utilizing this material for educational purposes.