Lose Your Marbles 2017

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We are inviting you to fill out our survey form. Share your opinions, join the fun, and maybe even win a raffle prize!
You will also be added to our event mailing list. All fields with asterisk are required to be answered for submissions. Please take a moment to complete this survey. This information assists the foundations and corporations that support us and keeps them informed as to who benefits from these performances. Information gathered will not be sold and is confidential.

Email *

What is your age and/or the ages of people in your party this evening?

This number includes how many males?

This number includes how many females?

Are you?

Single

Married

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What category best describes you and your party members?

Best identification of ethnicity (check all that apply)

African-American

Caucasian

Native American

Asian

Hispanic

Other:

What other live dance performances have you seen in the last year?

Last Name *

First Name *

Street Address *

City *

State *

Zip *

How did you hear about Lose Your Marbles A Dance Centric Event?

Phone Number (optional)

Compliments or Concerns

Do you wish to keep your name anonymous if you win our survey raffle?

Yes

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Submit

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