Guided Path Fireside Chat Guest Information Form

Thank you for agreeing to join us on the Guided Path’s Fireside Chat podcast. Please complete this form to help us prepare for your episode and highlight your unique story and expertise.

Guest Information

First name*

Last name*

Preferred Pronouns

Birthday

Month

Day

Year

Phone*

Email*

About You

Title or Role (check all that apply):*

Cancer Patient

Survivor

Caregiver

Medical Professional

Advocate

Volunteer

Other

Type of Cancer (if applicable):

Stage (if applicable):

Organization Affiliation (if applicable):

Brief Biography (please include any relevant personal, professional, or advocacy experience):

Fireside Chat Details

Why do you want to participate in the Fireside Chat podcast?

What topics or themes would you like to discuss during your episode?

Are there any specific challenges, successes, or stories you’d like to share?

Do you have any resources, projects, or initiatives you'd like us to mention?

Media Consent and Privacy Preferences

May we record and publish your episode across all Guided Path platforms (e.g., website, social media, podcast directories)?*

Yes

How do you prefer to be identified in the episode?*

Full Name

First Name Only

Anonymous

If you would like a tag line displaying your title and/or organizational affiliation, provide that information here (example: Founder/Guided Path):

Are there any topics or questions you prefer not to discuss?

Signature*

Signature field is empty.

Thank you for sharing your story and expertise with our Fireside Chat audience! Together, we’re creating a meaningful dialogue about advanced-stage and rare cancers.

info@guidedpathtcs.org

(423) 438-3799

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