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.