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Street address *
Street address 2 (optional)
City *
State *
believe chance hours
Zip code *
Phone *
Email *
Emergency contact person: *
Emergency contact phone where he/she can be reached DURING activities: *
Age *
What would you like to share about yourself that others should know about? *
Gender identity (select one) Male Female Gay Lesbian Trans man Trans woman Non-binary Not sure Other
Pronouns:
Where do you work? *
Do you work at least 20 hours per week? If not, how many hours a week do you average? *
Briefly describe your job duties (one or two sentences). *
Tell us about your strengths! What are you good at? What do you enjoy? List three things. *
What are your challenges? What are you afraid of? List three things. *
When I meet new people, I feel ... (Select one) * Happy and excited OK, neutral Nervous and anxious Overwhelmed Other
What are your hobbies and interests? *
Why are you interested in speed dating and friending?(This question is for dating programs only. Next Level Social attendees do not need to answer this.)
What do you hope to gain out of a speed dating and friending session?(This question is for dating programs only. Next Level Social attendees do not need to answer this.)
I feel ready to date. (This question is for dating programs only. Next Level Social attendees do not need to answer this.) Not at all A little Pretty much Definitely
How many dates have you been on in the past 3 years? (This question is for dating programs only. Next Level Social attendees do not need to answer this.) I have never been on a date 1-3 4-8 More than 8
I feel confident about dating. (This question is for dating programs only. Next Level Social attendees do not need to answer this.) Not at all A little Pretty much Definitely
How much help did you have in filling out this application? (Select one) * No help, completed independently A little help with the reading/writing/typing, but the words are all my own I had help putting my thoughts to words. Someone helped me answer most of the questions Someone else completed the application for me
How did you hear about this program? *
NPower Services Next Level Social and Friendship & Dating Program Acknowledgement NPower Services is excited to offer events and programs that help adults make new friends and explore healthy relationships. These programs are designed to be welcoming, inclusive, and fun. We believe that everyone deserves the chance to connect with others in meaningful ways. Before participating, please read and acknowledge that you understand the following: I Understand That: Making friends and dating can involve emotional and social risks. Sometimes, people may not act how we expect. Relationships may not always work out. I am responsible for how I choose to interact with others at these events. I am encouraged to speak up if I ever feel uncomfortable or unsafe. I Agree That: I am choosing to participate in friendship and/or dating events offered by NPower Services. I will treat other participants with kindness and respect. If I need support, I will talk to a trusted adult or staff member. I Understand and Accept: NPower Services, its staff, volunteers, and any partner agencies are not responsible for the actions or behaviors of other participants. I will not hold NPower Services or any related organization legally or financially responsible for any personal disappointment, emotional discomfort, or unwanted behavior that may result from friendships or relationships formed during these programs. I must also sign the general NPower Services Participation Waiver to attend any event. By completing this form, I confirm that I understand what is written above, and I agree to participate in a responsible and respectful way. *
