'DIS AGREEMENT' Application

Full Name: *

Age: *

Phone: *

Email: *

What is the core disagreement or conflict you want to discuss? *

Do you know the person you're in conflict with? *

If Yes, Opposing Party Details:

Their Name:

Contact Info:

Relationship to You:

Conflict Characteristics

Rate the intensity of your disagreement *

Potential Resolution Goals

What would an ideal resolution look like to you? *

Podcast Participation Agreement

By submitting this form, I agree to:

Participate openly and honestly
Respect the podcast format
Engage in constructive dialogue
Abide by the host's mediation process
Potentially change my perspective

Rate your openness to finding a middle ground: *

Why should you be selected for this podcast? *

Media Release

I agree to be recorded
I consent to potential video/audio distribution
I understand the podcast may be publicly shared

Signature: *

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