Your Name(Required)
This is your primary email, to which we will send relevant communications regarding this event.
This is the number through which we will contact you on the day of the event, in case of required last-minute communications.
Text Message Preference(Required)
If we contact you using the above phone number, how would you prefer to be reached?
Your Mailing Address(Required)
If you would like us to include an assistant when communicating with you, please provide their details below including name, phone number, and email address.
For this event, how would you like to be identified? (e.g. Author of [...], Professor at [...], Artist, Founder of [...])
Presenter bios should be about 75 words in length. If you would like to include personal information (hobbies, home life, likes, and so forth), this should be about one sentence in length.
Please include 1-2 links to your projects, website, book, etc. where participants can learn more about your work and how to further engage. Please include the website link and a brief description of the website. Additionally, we ask that you please provide up to 3-5 resources, organizations, articles, videos or podcasts you wish us to share in a resource guide attached to your episode if possible.
Please submit your photo with the following criteria: a high resolution photo that includes head and shoulders in JPEG format. We will crop photos for the web. By sending this photo, you are confirming that you have the copyright or permission to use the photo submitted to Mind & Life. You grant Mind & Life permission to use this photo for marketing purposes. The photo can also be sent directly to programs@mindandlife.org.
Accepted file types: jpg, jpeg, Max. file size: 50 MB.
Privacy Policy(Required)
Mind & Life's use of any information gathered during this registration and event is governed by the terms outlined in the Mind & Life Privacy Policy.
Consent to Release Information(Required)
The Mind & Life Institute and the undersigned, (the “Participant”), in consideration of the agreements herein set forth agree to the following terms and conditions:
  1. I, the undersigned Participant, hereby consent to the recording of my participation, appearance, and voice in connection with the ​Mind & Life​ program, ​known collectively as “the Program”,​ including, but not limited to materials contributed and used by me, including my biographical material and statements, whether alone or in conjunction with others, and my identification by name, together with all underlying and associated intellectual property and rights, all collectively described as the “Developmental Work”.​ ​The Developmental Work relates specifically to the events documented by Mind & Life via recording as noted above. The Participant remains the owner of the intellectual property related to their research.
  2. I, the undersigned Participant hereby grant to the Mind & Life Institute a royalty-free, exclusive license to use, paraphrase, edit, reproduce, display, perform and distribute the Developmental Work documented during the Program as long as Mind & Life will acknowledge my contribution to any intellectual ideas that emerge from the Developmental Work and whenever Mind & Life uses, paraphrases, edits and displays the Developmental Work.
  3. Upon written permission by the Participant​ here​, Mind & Life is granted permission to prepare derivative works of the Developmental Work, and to use, paraphrase, edit, reproduce, display, perform and distribute such derivative works.
  4. This Agreement constitutes the final, entire, complete and exclusive agreement of the Mind & Life Institute and the undersigned Participant regarding its subject matter and supersedes all prior and contemporaneous oral understandings and agreements and all prior written understandings and agreements.
  5. This Agreement may be modified only by written agreement of the parties. Any attempted assignment or delegation of this Agreement by either party without the prior written consent of the other party is void. This Agreement shall be governed by the laws of the State of Virginia, applicable to agreements made and to be performed entirely within the state, without reference to choice of laws principles. The parties have executed this Agreement as of the Submission Date of the form.