The Blac Shore Experience
Census Form
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Age Range
*
Please Select
21-30
31-40
41-50
51+
Interest & Lifestyle
*
Wine Tasting
Art and Culture Events
Networking and Social Mixers
Culinary Experiences
Live Music and Entertainment
Wellness and Self Care Experiences
How often do you typically attend social events
*
Please Select
Weekly
Monthly
A few times per year
Rarely
What do you hope to gain from this community
*
Expand my social circle
Business networking opportunities
Experience curated and exclusive events
Find like minded individuals
Other
What industry are you in?
Are you comfortable committing to a monthly membership fee?
*
Are you comfortable committing to a yearly membership fee?
*
How did you hear about The Blac Shore Experience
*
Social Media
Referrral
Event
Referral Name
First Name
Last Name
If you have experienced one of our events please leave us a testimonial.
Provide your Instagram username (handle) ie.. @blackshoreexperience
*
Provide your Facebook username (handle) ie.. theblacshoreexperience
*
Submit
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