Name:
City:
State/Province/Etc.:
Phone:

Birthdate:
Race:
Religion:
Occupation:
Current Education Level:
Sexual Orientation:
Gender:
If you are transgendered, are you transitioning? What does that involve for you, and where are you in that process?
What are you looking for?

Do you want someone of a particular gender or sexual orientation to mentor/bond with? Why?
How do you spend your leisure time?
Do you have any specials skills or hobbies?
Please list any traits which you might have difficulty dealing with:
If you'd prefer to print a copy
of this form to fill out and mail to us
at your convenience, use this version

For info, email aidan@nerdcore.zzn.com.