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Ask The Pastor Guest Form

Today's Date

MM/DD/YYYY

First Name

Last Name

Phenetic Spelling / Pronunciation of Your Name (Example: Alphabet = al-fuh-bet)

Church Name

Denomination

Church Mailing Address

Street Address

City

State

ZIP Code

Church Physical Address (If different than Mailing Address)

Street Address

CIty

State

ZIP Code

Home Address

Street Address

City

State / Province / Region

ZIP / Postal Code

Country

Church Phone

Church Fax

Website

Cell Phone

Date of Birth

MM/DD/YYYY

If Married, list spouse's name

Seminary

If yes, where?

Best time to contact you?

What days (M-F) would work best for you to be on Ask The Pastor?

Session

Year

Assistant's Name?

Assistant's Cell Number

List your social media information

On-Screen Graphics (Example: John Doe - Pastor or Reverend or Dr. or Bishop, etc.)

First Name

Last Name

Title

Additional Info and Accomplishments

I accept your invitation to participate in production of the “Program” specified below and hereby specifically authorize you (and your affiliated media distribution systems) to use my name, likeness, biographical information, voice and visual performance in the distribution of the Program, and for any promotional, advertising, or other marketing use that you may deem appropriate. I further authorize you to edit, air and reuse the Program, in whole or in part, as you deem appropriate for distributing via radio, television, satellite, microwave, cable, internet, close circuit exhibition or any other form of electronic or mechanical means throughout the world. I also agree, if by reason of my statements and/or actions on the Program or by materials furnished by me for the Program, a third-party claim, demand or suit for violation or infringement of rights and/or damages arises in connection with distribution of the Program, to hold you (and your affiliated media distribution systems) harmless from any liability, loss or expense incurred due to said claim, demand or suit.

First Name

Last Name

Date

MM/DD/YYYY

Ask The Pastor Guest Form

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Ask The Pastor Guest Form