People ages 50 + Living with HIV - Submission Form

  • People Living with HIV - Submission Form

  • Hi there! Thank you for your interest in our project featuring people living with HIV.

    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 self-recorded video 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 casting@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!

  • Format: (000) 000-0000.
  • Are you legally permitted / allowed to work in the United States?*

  • During this survey, we will be asking you about your medical history/health as it relates to your diagnosis of HIV. Please select "I agree" below if you are willing to share information about your health as it relates to your diagnosis 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.*

  • Now we'd like to learn about you and your HIV diagnosis & experiences.

  • Have you been diagnosed with HIV by a health care provider?*
  • Which age category best describes when you were diagnosed with HIV?*
  • Will you be able to provide proof of your HIV diagnosis if requested later in the process? (e.g. a doctor's note, etc.)*
  • Describe your relationship with your healthcare team: (Select all that apply.)*
  • Are you navigating HIV alongside aging, chronic health conditions, or other life challenges?(Select all that apply)*

  • Please upload a RECENT photo of yourself. 

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  • Thank you so much. Just a few more questions and you'll be done.

  • What is your age range?*
  • What is your ethnicity/race?*

  • 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?
  • As a part of the final selection process, would you consent to a Background Check?*
  • Rows
  • Are you comfortable appearing on camera with your face visible for this video?*
  • Are you comfortable filming in your home or community space (if applicable)?*
  • How did you hear about this project?*

  • 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?*

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

     Please click on the "Submit" button to complete your survey.

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