Renegade83 » Casting: My Feet Are Killing Me!

Name:*

First Last

Home Phone:

Mobile Phone:*

Birthdate:*

Your email address:*

Enter Email Confirm Email

Tell us where you live:*

City State

Current or previous occupation?*

Please explain your foot condition in detail.*

How long have you struggled with your foot condition?*

Have you been to a doctor about your foot condition?*

Yes
No

If yes, what was the outcome?*

How has your foot condition affected your life?*

Other than your feet issues, do you have any other health or medical issues we should know about?*

Yes
No

If yes, please explain:*

Please list all Surgeries that you have had:*

If you have had surgery before, did you have an issues?*

Yes
No

If yes, please explain:*

Are you allergic to any medications?*

Yes
No

Which ones?*

Do you currently take any medications?*

Yes
No

Which ones?*

Have you ever been arrested?*

Yes
No

If yes, explain the reason and circumstance:*

Have you ever been convicted of a crime?*

Yes
No

If required for the show, are you able to leave the state?*

Yes
No

Do you have health insurance?*

Yes
No

Do you have access to your medical records from your foot doctor?*

Yes
No

Please list all of your social media accounts with a link to each:*

Please upload your most recent medical records here:

Drop files here or

Max. file size: 10 MB.

By checking the box below you’re indicating that you have read, understand and agree with all "REQUIREMENTS & RELEASES" and our "PRIVACY POLICY"*

Click here to review our "REQUIREMENTS & RELEASES" and "PRIVACY POLICY".

I AGREE (you must agree to submit your application)

Follow Us

Have a question?

@Renegade83llc:

Our location: