Centenarian Form Centenarian's Information Full Name (required) Date of Birth (required) Gender Select OneMaleFemale Address Type Select OneOwn HomeAssisted LivingOther Street Address City State Zip Code Phone Number Is the Centenarian wheelchair bound? Select OneYesNo Is the Centenarian a veteran? Select OneYesNo In which branch did the centenarian serve? How many years of service? Best contact person/guardian or person filling this form Name (required) Email (required) Phone Number (required) Best address to receive USPS mail (preferably a family member or guardian's address) Name Street Address City State Zip Code Release for use of name, stories, photographs, artwork, and video As a contribution to the promotion of health and well-being among Utah citizens, permission is hereby given to the Utah Department of Human Services to use the name, stories, photographs, artwork, and videos of the individual/participant named below for publicity and educational purposes, in any and all publications, and other media accounts, without limitation or reservation. I understand that by checking this box I am granting permission for the Utah Department of Human Services to share my information in this and future years for promotion and recognition of the Centenarian Celebration and Yearbook. I have read and understand the above release and specifically agree to be bound by the terms set forth above. I waive any right to privacy for this information. Please leave this field empty.