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! 

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* 1. First Name

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* 2. Last Name

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* 3. Age

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

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* 5. Do you date:

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* 6. Your Height

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* 7. Your Job:

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* 8. Favorite weekend hobbies or activities?

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* 9. Describe yourself in a single sentence:

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* 10. What's your type? Be as detailed as possible. 

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* 11. Profile Photo

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No file chosen

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* 12. Additional Profile Photo

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No file chosen

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* 13. Your email address and phone number:

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