Media Interest and Release Form
| 415-434-3388 | 800-445-8106
Please read and check
I authorize Family Caregiver Alliance to release my name, phone number, and email address to interested members of the media.
District Of Columbia
Northern Mariana Islands
Phone or Cell Phone:
Your age (optional, but helpful)
Are you currently caregiving for a relative or friend?
Who are you caregiving (mother, spouse, friend, etc.)?
What is their diagnosis or diagnoses?
Your Media Interest
Please check the form(s) of media you are interested in contributing to:
Print / web (articles/column/blogs)
Radio / podcasts (news, talk, documentary)
Television (news, talk, documentary)
I am willing to
be recorded (radio or podcast)
be filmed (television or film)
none of the above
I am interested in sharing my experiences with
caregiving for family/friend
social service agencies
dementia and related caregiving
family caregiving policy (California)
family caregiving policy (National)
other (please describe in the following box)
OPTIONAL QUESTIONS (frequently asked by reporters)
Do you have experience with Paid Family Leave?
Do you get paid for your caregiving responsibilities through In-Home Supportive Services or other such programs?
Do you have a Personal Care Agreement (a written agreement outlining compensation — money, goods, property — in exchange for your caregiving)?
Do you have experience with care transitions, e.g.: hospital to home?
Are you employed full-time?
Are you employed part-time?
Are you a "sandwich caregiver" — caring for both parent(s) and child(ren)?
FCA will keep your information on file for potential media requests.
for your assistance!
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