First Name *

Last Name *

Email *

Phone

Please provide a brief description of what you do and who you help. *

What would you like to ensure we cover in our chat? And how do you think this would benefit my audience? *

Which one book has had the most impact on you in allowing you to become fearless? Charlotte will ask you this question at the end of your guest session.

Please include any links to your website, social media, Facebook group etc that you would like included in your show notes. *

Please attach a photo below for use in the marketing graphics, or alternatively email one to Matt at [email protected]

Document Upload

PLEASE READ AND TICK TO ACCEPT THE TERMS AND CONDITIONS

I hereby consent to the recording and distribution of reproduction(s) of my voice and performance as part of the media program entitled "Becoming Fearless" (herein referred to as the "Program"). This is to confirm that I, the undersigned, have agreed to be interviewed or otherwise participate in the Program, a production by Charlotte Carter.

As a condition of publication/broadcast and for no monetary compensation, Charlotte Carter requests the non-exclusive worldwide rights to reproduce and distribute my oral presentation, in whole or in part. Charlotte Carter shall have the right to edit and/or transcribe my presentation.

I also grant Charlotte Carter the right to use my name, biography and likeness in connection with the episode and related marketing.

I warrant that my presentation is original to me, that publication/broadcast will not infringe on the rights of others, and that I have full power to grant this license. Should my production/broacast incorporate copyrighted material of others, I warrant that I have obtained such permission from those parties for publication/broadcast by Charlotte Carter, consistent with this Agreement.

Execution of this Agreement does not obligate Charlotte Carter to publish my presentation or other materials.

I hereby consent to the use of my oral and/or video presentation as described and agree with the provisions of this release form.