Potential Participant Survey

To participate in the Agenda Blind Date matchmaker program, you must be over 21, single and live in Charlotte. By filling out this form, you agree that we can use this information when we publish a story. Additionally, you must agree to a phone interview if we end up choosing you for a date. Feel free to elaborate on any/all of these questions if you'd like to clarify anything. Read our Privacy Policy and Terms of Use. Questions? Email lauren@charlotteagenda.com. Thanks! 

Question Title

* 1. First Name

Question Title

* 2. Last Name

Question Title

* 3. Age

Question Title

* 4. My ideal date would be between the ages of:

Question Title

* 5. With which gender identity do you most identify?

Question Title

* 6. Do you date:

Question Title

* 7. Your Height

Question Title

* 8. How important is a date's height to you?

Question Title

* 9. Your Job:

Question Title

* 10. How long have you lived in Charlotte & where did you live before moving here?

Question Title

* 11. Favorite things to do in Charlotte?

Question Title

* 12. Top 3 Charlotte restaurants?

Question Title

* 13. Top 3 favorite Charlotte bars?

Question Title

* 14. Favorite type of music? (select all that apply)

Question Title

* 15. Favorite Movie?

Question Title

* 16. Favorite Book?

Question Title

* 17. What's your favorite and least favorite part about Charlotte?

Question Title

* 18. Favorite Charlotte neighborhood?

Question Title

* 19. What's your workout style/schedule?  (Yes, it's OK to say none.)

Question Title

* 20. Describe your political preference

Question Title

* 21. How would your best friend describe you?

Question Title

* 22. What if your date has opposing political views?

Question Title

* 23. Ideal first date? (Be specific, we're trying to make it happen!)

Question Title

* 24. Your best joke, pick up line or icebreaker?

Question Title

* 25. Do you have children, or want them?

Question Title

* 26. What if your date already has children?

Question Title

* 27. Have you been married previously?

Question Title

* 28. Are you open to dating someone outside your race?

Question Title

* 29. What religion are you and should your partner share those views?

Question Title

* 30. Do you drink?

Question Title

* 31. Do you smoke?

Question Title

* 32. Is smoking a deal breaker for you?

Question Title

* 33. What's your favorite binge watch on Netflix?

Question Title

* 34. Do you own a pet? If not, why? Provide details.

Question Title

* 35. Describe yourself in a single sentence:

Question Title

* 36. What's your type? Be as detailed as possible. *Not for publication

Question Title

* 37. What are your deal breakers? Be as detailed as possible. *Not for publication

Question Title

* 38. Profile Photo

DOCX, DOC, JPEG, GIF, JPG, PDF, PNG file types only.
Choose File
No file chosen

Question Title

* 39. Why should we select you?

Question Title

* 40. Additional Profile Photo

DOCX, DOC, JPG, GIF, JPEG, PDF, PNG file types only.
Choose File
No file chosen

Question Title

* 41. Your email address and phone number:

T