Name & Birthday: ______________________________________

Spouse’s (or Significant Other’s Name) & Birthday:

______________________________________________________

Email Address_______________________ (work or personal)

Wedding Anniversary: __________________________________

House Purchase Date: ____________________________________

Please check the following items so we can get to know you better:

What activities do you like to do? Please write in the initials of who likes what. 

Put F it’s something you do as a family:

___ Going Out for Ice Cream ____ Working Out

___ Going to the movies ___ Ice skating ____Roller Skating

___ Golf ___ Bowling ___ Mini-golf ____Going for Coffee or Tea

___ Renting movies ___ Outdoor activities: Please list: __________

______________________________________________________

______________________________________________________

Where do you like to eat:

___ Pizza Where? _______________________________________

___ Burgers Where? _____________________________________

___ Fine dining Where?___________________________________

___ Italian Where?_______________________________________

___ Mexican Where?_____________________________________

___ Oriental Where?_____________________________________

___ Other(s): __________________________________________

Children’s Names & Date of Birth:

1. __________________________ Date of Birth___________

2. __________________________ Date of Birth___________

3. __________________________ Date of Birth___________

4. __________________________ Date of Birth___________

5. __________________________ Date of Birth___________

Please indicate the interests and activities in which you and/or your spouse/partner 

enjoy participating in on a regular basis: