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Black and Dyslexic Podcast Interest Form
Thank you for your interest in being a guest on the Black and Dyslexic Podcast. Hosted by Winifred A. Winston and LeDerick Horne. A safe space to have unfiltered discussions into all things Black and Dyslexic.
We plan to start interviewing in mid March; we will be in touch soon with next steps and for you to select a date/time.
Enthusiastically,
Black and Dyslexic Podcast Team
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Today's Date
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Ms
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Mr
Master
Rev (Reverend)
Fr (Father)
Dr (Doctor)
Atty (Attorney)
Prof (Professor)
Hon (Honorable)
Pres (President)
Gov (Governor)
Coach
Ofc (Officer)
Senator
Name (First Name, Last Name)
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Segment / Topic(s) of Interest
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Bad Azz Parent Segment
Person with Lived Experience
Special Education Advocacy
Literacy / Structured Literacy / OG
Dyslexia Screening / Neuropsychological Testing
Related Service (OT, Speech, Executive Function Coaching)
Higher Education/Teacher Prep
Higher Education / Accommodations
Neurodiversity in the Workplace
Assistive Technology
Health & Wellness (including mental health)
K-12 (Public and Private Schools)
Other:
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Please provide a short bio (150 words max)
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Race/Ethnicity
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Hispanic or Latino
White
Black or African American
Native Hawaiian or Pacific Islander
Asian (Not Hispanic or Latino)
Native American or Alaska Native (Not Hispanic or Latino)
Two or more races (Not Hispanic or Latino)
List your social media handles to list in the show notes.(LinkedIn, Facebook, Instagram, Twitter, Pinterest , ClubHouse, Website, etc)
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Phone number (best number to reach you; this will be for our records only)
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Email Address (for our records only - we will send your zoom link invite here)
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Mailing Address (for our records only)
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Signature (please type your name; this constitutes your electronic signature)
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