The Well Membership Application

Shana Connects

Please complete the entire form, and add a picture.

Membership Information

First Name*

Last Name*

Email*

Phone*

Location

How did you hear about us?

If friend, family or other, please tell us who referred you

Photo*

Basic Information

Gender*

Birthdate*

Relationship Status

Ethnicity

Faith/Religion*

Education*

Occupation*

Income

Do you have children?*

How many children do you have?

Do you want children/more children?*

Height *

Body Type

Hair Color

Eye Color

Languages spoken

What is your political affiliation?

Do you smoke?

Do you drink?

Do you have pets?

Do you have any pet allergies?

About Me

What activities do you enjoy?

Brief Bio

Match Preferences

Preferred Gender*

Preferred Education Level

Preferred Relationship Status

Preferred Age Range

Preferred Faith/Religion

Preferred Ethnicities

Preferred Body Type

Preferred Height Range

Would you date someone with children?

Preferred Political Affiliation

Would you date someone who smokes?

Would you date someone who drinks?

Describe your ideal partner*

My deal breakers*