Vitiligo Submissions

Vitiligo**

Hi there. Thank you for your interest in our project featuring Adults and Teens with Vitiligo. DO NOT SUBMIT UNLESS YOU HAVE NON-SEGMENTAL VITILIGO.
DO NOT SUBMIT UNLESS YOU HAVE NON-SEGMENTAL VITILIGO. 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 research@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*

First NameLast Name
If you are a minor, please list your Parent/Guardian's name here.
Phone Number*

Area CodePhone Number
E-mail*
Where do you live?*
City, State
If your Talent Rep submitted you for this, please list their name and contact info below.

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

YesNoI don't know

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 Vitiligo condition, which is considered medical history/health information covered by HIPAA.

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 are knowingly waiving your rights under HIPAA and any other privacy laws and 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 waive my rights under HIPAA and any other privacy laws and permit GENUINE to store and access my personal health information for purposes of contacting me for projects.I decline to provide my personal health information.

Now we'd like to learn about you and your experience with Vitiligo.
Have you been diagnosed with Non-Segmental Vitiligo?.*

YesNoDon't Know
When were you diagnosed with Vitiligo?*
How do you feel about living with Vitiligo? *
What advice would you give to someone who has just been diagnosed with Vitiligo?*
If selected, would you be comfortable appearing on-camera and showing your Vitiligo?*

YesNoI'm not sure
What advice would you give to someone who has just been diagnosed with Vitiligo?*

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

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!
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.
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Vitiligo**