Anti-Stigma Campaign | Video Open Call

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If you are interested in taking part of the Anti-Stigma Campaign video, please fill out the form below. Everyone is welcome to submit this form, but personal accounts of stigma are solely for PLWH. Please note, the Consumer Committee will make final cast decisions on October 7th and everyone invited to participate will be notified shortly after to schedule an evening within the last 2 weeks of October that would work best with their schedules.

FORM SUBMISSION DEADLINE: Monday, October 7th BY NOON

Email *

Name *

Age

Under 20

20-29

30-39

40-49

50-59

60-69

70+

Clear selection

Gender

Female

Male

Transgender (Male to Female)

Transgender (Female to Male)

Gender Fluid

Other (Please Specify) ________________________________________

Clear selection

Are you Latinx, Hispanic or Spanish?

Yes

Clear selection

What is your race? (Please select all that apply)

American Indian/Alaskan Native

Asian

Black/African American

Native Hawaiian/Pacific Islander

White/Caucasian

Prefer not to answer

Other (Please Specify) ______________________________

Which SPOKEN language do you speak most of the time?

English

Spanish

Cape Verdean Creole

Portuguese

Haitian Creole

French

Swahili

Other (Please Specify) ___________________________________

Clear selection

What is your current zip code?

Are you comfortable being on camera?

Yes

Clear selection

If you are submitting a personal story of stigma, are you comfortable sharing it on camera for the video?

Yes

Clear selection

Are you living with HIV?

Yes

Do not wish to answer

Clear selection

Are you available for at least one evening video shoot between Monday, October 14th and Thursday, October 31st? (Dates TBD, but every shoot will be after 5p)

Yes

Maybe (Please Provide Details) _________________________________________________________________

Clear selection

Would you be willing to shoot short scenes with others in the video?

Yes

Maybe

Clear selection

If you are person living with HIV and would like to share a personal account of being stigmatized, please share some details so we can get to know your story.

A copy of your responses will be emailed to the address you provided.

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