Speed Dating Application
Feb. 2023 - Irish Pub Rex Location
Name
First Name
Last Name
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Drivers License (or State Issued ID) State and Number
Do you understand that you will have to sign a "Speed Dating Participant Waiver" in order to participate in the event ?
Yes
No
Please indicate your gender
Female
Male
Other
Please select the category that includes your age
18-24
25-34
35-44
45-54
55-older
Please select the category that you are looking to possibly date
18-24
25-34
35-44
45-54
55-older
Do you smoke?
Yes
No
How would you describe your personality?
Shy and naive
Brave and talkative
Easy-going and cheerful
Honest and reliable
Sympathetic and tolerant
Energetic and open minded
Other
What traits do you look for in a partner?
Kind
Energetic
Honest
Naive
Talkative
Moody
Open minded
Respectful
Passionate
Good looks
Other
What kind of music puts you in the mood?
Soul music
Jazz
Blues
Classical music
House music
Rock
Country
Alternative
Hip Hop
Other
What's your favorite international food?
Pizza
Pasta
Sushi
Hamburger
Other
How do you feel about pets and animals?
not very much
1
2
3
4
very like
5
1 is not very much, 5 is very like
How would you describe an ideal day?
What's your dream date night?
What's the number one thing that you think makes a relationship last?
Submit
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