Potential Participant Survey

To participate in the Axios Blind Date program, you must be over 21, single, and live in Charlotte. By filling out this form, you're agreeing to being photographed/recorded by an Axios reporter and detailing your evening for an upcoming article and/or social post. Read our Privacy Policy and Terms of Use. 

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* 1. Are you willing to share a photo of yourself and your first name as part of the series?

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* 2. First and 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 hobbies/interests?

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* 9. Describe how you’d spend an ideal day in Charlotte:

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* 10. Neighborhood (general area you live in)

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* 11. Describe yourself in a single sentence.

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* 12. Describe your ideal match in a sentence.

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* 13. Why should we select you?

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* 14. Profile Photo

DOCX, DOC, JPEG, GIF, JPG, PDF, PNG file types only.
Choose File

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* 15. Additional Profile Photo

DOCX, DOC, JPG, GIF, JPEG, PDF, PNG file types only.
Choose File

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* 16. Link to Instagram (optional):

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* 17. Your email address and phone number:

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