First Name*:
Surname*:
Email Address*:
Mobile*:
Other Contact Number:
Suburb*:
Gender*:
Date of birth*:	Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 40 25 26 27 28 29 30 31 Month January February March April May June July August September October November December Year 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1940 1940 1931 1930 1929 1928 1927 1926 1925 1940 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909
Postcode*:
Profession:
Current marital status:	Divorced Separated Widowed Single
Do you have children?	Yes No
If yes, how many school-aged kids do you have?	0 1 2 3 4 5 6
Would you prefer to attend events:	During school holidays Outside of school holidays It doesn't matter to me
Preferred nights to attend events	Mon Tues Wed Thu Fri Sat Sun Tick as many as you like
What social activities do you like to do on the weekend (hobbies/interests)?
What types of activities are you most likely to attend (hold down ctrl to select multiple):	speed dating parties dining events dating workshops Other
If other, specify:
Promotional Code
I would like to:	register and pay for the next event  receive details about upcoming events and special offers
How did you first find out about Quick Connections?*
If word of mouth, please specify the person's name so we can thank them.?*
If other, specify:
Which social networking sites are you on? (hold down ctrl to select multiple)	Facebook Myspace LinkedIn Bebo Twitter Other
If other, specify:
Preferred location:	Illawarra (Wollongong) Sutherland Shire (Cronulla/ Gymea/ Miranda) Other

Bringing Friends?

Please fill in the form below if you'd like to register your friends. If you plan to come on your own, just leave this section blank and click 'Submit' down the bottom of the page.  

Learn about our Referral Program here.

Would you like to bring any friends?	Male Friend(s)     Female Friend(s)
Male Friends			Female Friends
Friend 1			Friend 1
First Name*:			First Name*:
Mobile*:			Mobile*:
Email*:			Email*:
Age*:			Age*:
Friend 2			Friend 2
First Name*:			First Name*:
Mobile*:			Mobile*:
Email*:			Email*:
Age*:			Age*: