Centenarian Form

Centenarian's Information

Full Name*

Date of Birth*

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*

Email*

Phone Number*

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.

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