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Your Name Please type in a name.

Your City of residence Please enter the city you live in.

The State you live in Please enter your state you live in.

Your Email address Please enter an email address.Please type a valid email address

(optional) Phone number A value is required. Please use the form (555) 123-4567.

Your Date Of Birth Please enter your birth date as mm/dd/yyyy.Please use mm/dd/yyyy format.

Your Gender Male Female

Please select your Ethnicity Please select what best describes your ethnic identity.

Type of relationship you seek Long term Casual Undecided

Do You have Children? Please select the appropriate answer.

Your Employment info Please select your current employment status.

Do you use Tobacco Alcohol Marijuana

Check any activity below that you enjoy doing
Reading	Playing a musical instrument	Cooking	Watching movies
Gardening	Playing card games/Mahjong	Walking	Attending church
Hiking	Bird Watching	Camping	Going to hear live msic
Traveling	Hunting or Fishing	Dancing	A workout at the gym

type some disclaimers here

Inputting Information:

When you type in your Name, any name will do. You can put in your real name, a nickname or an alas. We don't care.
Your City, State and Email address are obvious and required. The Phone number is optional unless you do not have an email address, in which case, please provide your phone number and we will contact you via text message when necessary. No one will call you.
When entering your Date Of Birth Please use the format: mm/dd/yyyy