| |
|
| Personal Information |
|
| Solutation |
Check only one
-----Please select-----
Sir
Madam
Mr.
Mrs.
Miss
|
| Date of Birth |
__________
|
| Place of Birth |
__________________________________________________
|
| Marital Status |
Check only one
-----Please select-----
Single
Not Single Anymore
Committed
In PACS
Married
Separated
Not Married Anymore
|
| Country of Origin |
__________________________________________________
|
| Your First Language |
__________________________________________________
|
| Your second language, other than English, is |
__________________________________________________
|
| Do you consider yourself to be first generation immigrant? |
|
| How long have you been speaking English on the everyday basis? |
__________________________________________________
|
| You relocated to the United States between the years of |
Check only one
-----Please select-----
Before 1960
1961 - 1969
1970 - 1979
1980 - 1989
1990 - 1999
After 2000
|
| Education |
Check only one
-----Please select-----
School only
Some College
Bachelor
Masters
PhD
Post-Doctoral
Independent but subject oriented
|
| Major, if applicable |
__________________________________________________
|
| Profession |
__________________________________________________
|
| Occupation |
__________________________________________________
|
| What weekdays are you available for evenings? |
__________________________________________________
|
| What time of day are you available on Saturday? |
Check all that apply
8am - noon
8am - 2pm
10am - 2pm
2pm - 7pm
6pm - Midnight
All day
|
| What time of day are you available on Sunday? |
Check all that apply
8am - noon
8am - 2pm
10am - 2pm
2pm - 7pm
6pm - Midnight
All day
|
| How would you like to be contacted about our future events? |
Check only one
-----Please select-----
Telephone
Email
Fax
Mail
Telephone one and email
|
| Fax |
__________________________________________________
|
| You prefer the following method of payment per event that appeals you: |
Check only one
-----Please select
Credit Card Online
Credit Card by Phone
Check or Money Order by Mail
Cash, Money Order, or Check in Person
|
| How did you find out about EuroLEAVES |
__________________________________________________
|
| What objectives do you pursue by attending EuroLEAVES' events? |
Check only one
-----Please select-----
Dating
Friendship
Networking
Cultural exposure
Entertainment
Social interaction
Other
|
| If 'other', please specify: |
__________________________________________________
|
|
| OPTIONAL PART |
THE FOLLOWING QUESTIONS ARE OPTIONAL AND ARE FOR YOUR PERSONAL INTEREST & BENEFIT ONLY.
|
| What kind of people are you interested in meeting? |
|
| Age |
__________________________________________________
|
| Origin |
__________________________________________________
|
| Education |
__________________________________________________
|
| Gender |
Check only one
-----Please select-----
Male
Female
Male & Female
No preference
|
| Occupation |
__________________________________________________
|
| Income |
__________________________________________________
|
| Personal Qualities you value the most |
__________________________________________________
|
| Which philosophers' views, if any, do you find compatible with yours? |
__________________________________________________
|
| Do you follow traditions of any religion and of which if yes? |
__________________________________________________
|
| What painter(s) do you find most appealing to you? |
__________________________________________________
|
| What genre of music do you prefer? |
__________________________________________________
|
| Would you say that reading poetry takes…of your reading exposure? |
Check only one
-----Please select-----
0
1/4
1/3
1/2
2/3
all
|
| What about reading fiction? |
Check only one
-----Please select-----
0
1/4
1/3
1/2
2/3
all
|
| And what about philosophy? |
Check only one
-----Please select-----
0
1/4
1/3
1/2
2/3
all
|
| Your favorite novelist? |
__________________________________________________
|
| Your favorite writer? |
__________________________________________________
|
| Name three of your best qualities |
__________________________________________________
|
| Name at most four of the qualities you consider negative? |
__________________________________________________
|
| Your skill levels in the following activities: |
|
| Kayaking |
Check only one
-----Please select------
Pro
Moderate Skills
It has been a while
Need some training
No skills, but would like to learn
Have no interest in the activity
|
| Bridge |
Check only one
-----Please select-----
Pro
Moderate Skills
It has been a while
Need some training
No skills, but would like to learn
Have no interest in the activity
|
| Russian Whist (PRE-FE-RA'NCE) |
Check only one
-----Please select-----
Pro
Moderate skills
It has been a while
Need some training
No skills, but would like to learn
Have no interest in the activity
|
| Polo |
Check only one
-----Please select-----
Pro
Moderate Skills
It has been a while
Need some training
No skills, but would like to learn
Have no interest in the activity
|
| Skiing |
Check only one
-----Please select-----
Pro
Moderate skills
It has been a while
Need some training
No skills, but would like to learn
Have no interest in the activity
|
| Snowboarding |
Check only one
-----Please select-----
Pro
Moderate skills
It has been a while
Need some training
No skills, but would like to learn
Have no interest in the activity
|
| Cricket |
Check only one
-----Please select-----
Pro
Moderate Skills
It has been a while
Need some training
No skills, but would like to learn
Have no interest in the activity
|
| Volleyball |
Check only one
-----Please select-----
Pro
Moderate skills
It has been a while
Need some training
No skills, but would like to learn
Have no interest in the activity
|
| Tennis |
Check only one
-----Please select-----
Pro
Moderate Skills
It has been a while
Need some training
No skills, but would like to learn
Have no interest in the activity
|
| Golf |
Check only one
-----Please select-----
Pro
Moderate skills
It has been a while
Need some training
No skills, but would like to learn
Have no interest in the activity
|
| Soccer |
Check only one
-----Please select-----
Pro
Moderate skills
It has been a while
Need some training
No skills, but would like to learn
Have no interest in the activity
|
| Salsa or other specialized dancing |
Check only one
-----Please select-----
Pro
Moderate Skills
It has been a while
Need some training
No skills, but would like to learn
Have no interest in the activity
|
| Group Activities |
Please mark of the group activities would you be interested in, regardless of your proficiency in a given activity. (Please be so kind to note that EuroLEAVES does provide professional personal assistance during each and every event that requires certain skills.)
|
| Art Exhibitions |
|
| Poetry Contests |
|
| Concerts |
|
| Celebration of holidays originated in countries of Europe |
|
| Masquerade or other themed events |
|
| Specialized Dancing (Salsa, Ball Room, etc) |
|
| Discotheque |
|
| Bridge and Other Intellectual Card Games |
|
| Kayaking |
|
| Polo |
|
| Golf |
|
| Tennis |
|
| Cocktails |
|
| Professional and Business Networking |
|
| Balls and Galas |
|
| EuroTRIVIA and other intellectual games/competitions |
|
| Skiing Trips |
|
| Camping |
|
| Wine Tasting Weekends |
|
| Soccer |
|
| Other |
__________________________________________________
|
|
| - |
ALAS! Thank you for your time and patience!
We will take all of the provided information into consideration to make your
experience with EuroLEAVES most pleasant and memorable. After you are notified
about the event, you will be supplied with a web link where you can pay per each
event you would like to attend. Please make sure to read about a given event on
the pages of our web site before you decide to commit your time to an event.
WE WISH YOU A LIFE FULL OF JOY AND ADVENTURE!
WE LOOK FORWARD TO MEETING YOU AT ONE OF OUR EVENTS!
The Pleasure is Truly Ours,
Rene Iskander & Tatyana Vladi.
|