Application for Chiari & Chaos / Contact

🎙 Chiari & Chaos Podcast Guest Application

Name *

Email address *

Phone Number: *

Location (City, State, or Country): *

Tell us a little about yourself: (Who are you, and what do you want the audience to know about you?) *

What is your connection to Chiari Malformation? *

I have Chiari
I am a caregiver or loved one
I am a medical professional
I am an advocate
Other: __________

Please share a brief summary of your Chiari journey or the story you'd like to tell on the podcast: (This helps us understand the direction of your episode.) *

Why do you want to be on the podcast? *

Are there specific topics or experiences you want to highlight during your episode? (Examples: diagnosis journey, surgeries, parenting with Chiari, mental health, daily life, advocacy, etc.) *

Do you have any audio/video recording experience? *

Yes
No
A little

Do you have access to a quiet space and internet connection for recording? *

Yes
No

Are you comfortable being recorded and having your story shared on public podcast platforms? *

Yes
No
I have questions (we’ll contact you)

Social Media Handles or Website (optional):

Upload a photo of yourself (optional, for promotion of your episode):

Is there anything else you’d like us to know?

Send me a copy

Thank you again for your interest! If selected, we’ll contact you to schedule a recording and prep for your episode. 💜