Intake Form
Basic Information
Legal Name
*
First Name
Last Name
Email
*
example@example.com
Date of Birth
*
-
Month
-
Day
Year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Occupation
*
Faith & Theology
Your Denomination
*
Church Attendance
*
Weekly
Biweekly
Sometimes
Holidays
Are you actively serving in ministry or at your church?
*
Yes
No
How important is it that your spouse share the same denomination as you?
*
Not important
1
2
3
4
5
6
7
8
9
Must be the same
10
1 is Not important, 10 is Must be the same
How important is your faith to you?
*
Not that important
1
2
3
4
5
6
7
8
9
My life revolves around my faith
10
1 is Not that important, 10 is My life revolves around my faith
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Lifestyle & Values
Select ALL that apply:
Smoking (cigarettes)
Smoking (weed)
Smoker (weed + cigarettes)
Drinking (socially ONLY)
Drinking (wine and/or beer ONLY)
Drinker (liquor, wine, beer, etc)
Drug use
None
Introvert or Extrovert
Introverted
Balanced
Extroverted
Describe your lifestyle
*
Active (gym, hiking, nature)
Love going out
Homebody
Traveler
Hobbies?
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Relationships
Status
*
Never married
Divorced
Widowed
Children
*
Single parent
Shared custody
None
If you have children, how many do you have?
Numbers only
Do you want children?
*
Yes
No
Not sure
Are you open to dating someone with children?
*
Yes
No
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Partner Preferences
Here is where the fun begins! This section will ask preference related questions
Preferred age range:
*
I am open to dating someone who lives (select ALL that apply):
*
Anywhere in the US (open to long distance)
Within 4 hours of me
Within my state
Within my city/metro area
I am open to relocation
I am not open to relocating
Denomination preferences (select ALL that apply):
*
Pentecostal
Baptist
Catholic
Nondenominational
Lutheran
Jewish
No preference
Other
What occupations are you drawn to:
Nationality (select ALL that apply)
*
Black
White
Asian
Mixed race
Hispanic
Indian
Other
Hair color:
Blonde
Brown
Red
Doesn't matter
For MEN: Body type (select ALL that apply):
*
Athletic
Thin
Curvy
Very Curvy
Plus Size
Other
For WOMEN: Body type (select ALL that apply):
*
Athletic/lean
Thin
Muscular
Husky
Plus Size
Other
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Photo & Media Uploads
Please upload the requested pictures as JPEG, PNG, JPG; NO HEIC files please!
Photo
*
Browse Files
Drag and drop files here
Choose a file
No shades, hats, visors, or group pictures
Cancel
of
Full body photo
*
Browse Files
Drag and drop files here
Choose a file
No group pictures, or pictures with exes
Cancel
of
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Closing:
Final questions and agreements
Why are you interested in Holy Nation Connections?
*
What are you hoping to get out of this experience?
What would make you say the program was worth it at the end of the 8 weeks?
Agreements
I confirm the information provided is truthful and accurate.
*
Yes
No
I understand that selection into Holy Nation Connections is NOT guaranteed
*
Yes
No
I understand that no relationship or spouse is guaranteed
*
Yes
No
I understand that participation in group photos is optional
*
Yes
No
Submit
Should be Empty: