25-39 Family Caregivers Project

Caregivers Submission Form

Hi there. Thank you for your interest in our photoshoot project featuring family caregivers who have utilized a senior care referral service for their loved ones.
Please fill out the survey below ASAP. It should only take a few minutes. Once submitted, you may be contacted by a GENUINE Casting Team member for a follow-up photos to be viewed by our team and clients.

If you experience difficulty taking this survey or have questions about the project, please contact GENUINE at recruiting@genuinerp.com

If you have any questions about the information you provide to us, you can read GENUINE's Privacy Policy.

Okay, let's get started!
Full Name (Caregiver/Care Partner)*

First NameLast Name
Full Name (Senior)*

First NameLast Name
Phone Number*

Area CodePhone Number
Email*
City*
City, State
State*
Are you local (able to work local) to the Chicago, IL-area?*

YesNoI'm not sureOther

Are you legally permitted / allowed to work in the United States?*

YesNoI don't knowOther

We'd like to learn more about you, so tell us a little about yourself.
What do you do for a living? What do you do outside of work for fun? Ex: Passions, Hobbies, Activities, etc.*
What is going on in your life that you would like to share?*

During this survey, we will be asking you about your loved one's medical history/health as it relates to you being a family caregiver. Please select "I agree" below if you are willing to share information about your loved one's health as it relates to your story for the purposes of recruiting for this project.

MEDICAL CONDITIONS

Subject to your agreement to the waiver below, please share information regarding any medical conditions that you may have and are comfortable discussing publicly for potential projects. You acknowledge and understand that your personal health information may be protected from disclosure by the Health Insurance Portability and Accountability Act ("HIPAA") and other privacy laws. By selecting, "I agree" below, you consent to GENUINE electronically storing the personal health information that you disclose and reviewing it for purposes of contacting you about future projects for which you may be suited.
By selecting one of the options below, you acknowledge that you have read and understand the above statement.*

I agree to share personal health information with GENUINE for the purpose of recruiting for this project and permit GENUINE to store and access that information for the purpose of contacting me for future projects.I decline to provide personal health information.

Thank you so much. Just a few more questions and you'll be done.
Please upload a recent photo of yourself.

Browse Files
NO sunglasses, hats or edited/photoshopped photos. NO filters. We must be able to see your [real] face. Cancelof

Our company and our client do not discriminate on the basis of gender identity or gender expression. In order to track the effectiveness of our recruiting efforts and ensure we consider the needs of our project, please consider the following questions optional.
What is your gender?*

FemaleMaleNon-binary / third genderPrefer not to sayOther

As a part of the final selection process, would you consent to a Background Check?*

YesNo

GENUINE is always looking for people to share their stories and appear in paid advertising campaigns for major brands including American Express, Chipotle, and Walmart to mention a few.

If you would like to hear about our latest casting opportunities, join GENUINE's mailing list.

YOU ONLY NEED TO REGISTER ONCE, so if you receive our emails, please check, "I am already on the GENUINE Mailing List". Thank you!
Would you like to be added to GENUINE's mailing list?*

Yes! I would like to join GENUINE's mailing list and agree to permit GENUINE to store and access my contact information for purposes of contacting me for future casting opportunities.No, I decline to join GENUINE's mailing list at this time.I am already on the GENUINE mailing list.

Thank you so much for taking the time to answer all of our questions.

Please click on the "Submit" button to complete your survey.
Should be Empty:

	Yes	No	I'm not sure
I have been paid to work as an actor and/or model
I have been featured in a project for TV, Film and/or Digital Media.
I currently have or am seeking representation/an agent /a manager.
I have booked a project with GENUINE in the past.
I am a member of SAG-AFTRA.
I am a member of AEA.
I am pursuing professional acting / modeling opportunities.

Caregivers Submission Form