Online Registration

Online Registration Form

THE KSMS LOVE CONNECTION
Your Full Name
D.O.B. (MM/DD/YYYY)
Cell Phone
Zip Code
Email
FACEBOOK OR INSTAGRAM
What would you like to see happen on this Date? (Won't Be Posted Online)
Please note that lying about this being either your First or Second date will Disqualify you from ALL future 92Q Contest.

Please help us do this right by being honest!
Should be Empty:

Online Registration Form