Normal Big Very Big Centenarian's Information Name(including maiden name for women) Phone Number Email Address Street Address City Zip Date of birth (MM/DD/YYYY) Place of birth Father's Name Mother's Name Siblings Number of Brothers 0 1 2 3 4 5 6 7 8 9 Brother Still living 0 1 2 3 4 5 6 7 8 9 Number of Sisters 0 1 2 3 4 5 6 7 8 9 Sister's Still Living 0 1 2 3 4 5 6 7 8 9 Names and Birth Order(including yourself) Born First Born Second Born Third Born Fouth Born Fifth Born Sixth Born Seventh Born Eighth Born Ninth Born Tenth Born Elevents Born Twelfth Born Thirteenth Born Fourteenth Born Fifteenth Born Sixteenth Born Seventeenth Born Eighteenth Born Nineteenth Born Twentieth Number of Descendants How many children? Grandchildren? Great-grandchildren? Great-great-grandchildren? Have you already submitted information for a past year book? Yes No Brief Personal History What are your outstanding memories? (Suggestions: Childhood experiences, school years activities, employment, hobbies, and activities that you have enjoyed, travels, courtship, marriage, family life, and anything else you wish to include.) What are your favorite accomplishments? What schools did you attend, and what degrees/diplomas did you earn? What are the most impressive changes that you have seen over your lifetime, and how do you feel about those changes? What hobbies and activities do you currently enjoy? What is your secret to longevity? What would be your best piece of advice to anyone reading the yearbook? Thank you For your interest in having your story included in the 2013 Century Club Yearbook. We are looking forward to receiving your life story and photographs.
