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2024 Centenarian Survey

Successful Aging Centenarian Celebration
Application & Social History

This form must be submitted by August 13, 2024.

The form will be electronically submitted upon completion. You may also print the form, complete and return to admin@seniorservicesalex.org or:

Senior Services of Alexandria
Attention: Centenarian Program
206 North Washington Street, Suite 301
Alexandria, VA 22314

Centenarians will be recognized on September 10 at 5 p.m. in the Vola Lawson Lobby of Alexandria City Hall (301 King Street).

CENTENARIAN INFORMATION

1. Date of submission *This question is required. This question requires a valid date format of MM/DD/YYYY.

calendar

2. Centenarian's name *This question is required.

3. Name to be printed on the certificate (Include and suffixes or middle names/initials) *This question is required.

4. Centenarian's age *This question is required.

5. Year of birth *This question is required.

6. Centenarian's email This question requires a valid email address.

7. Centenarian's phone number

8. Centenarian's mailing address for certificate *This question is required.

9. Living arrangement (list name of facility if applicable):

Submitter’s Information:

10. Name *This question is required.

11. Relationship *This question is required.

12. Phone number *This question is required.

13. Email address *This question is required.

Resident’s Social History
The questions below are prompts and are not all required. Some may be skipped if you wish. The responses will be used to write a brief summary to tell the story of your life well-lived in a presentation during the Centenarian Celebration on September 10 at 5 p.m. in the Vola Lawson Lobby at City Hall.

14. Tell about your family (siblings, spouse, children, grandchildren, special pets, etc):

15. Tell about your primary occupation (including retirement information and/or military affiliation):

16. Please describe something interesting about your early years.

17. Describe any of your hobbies, interests, favorite sports teams, etc. (past or current):

18. What is the most important invention during your lifetime?

19. What makes you happy?

20. What advice would you offer to a younger person?

21. How important is your faith to you?

22. What is the secret to your longevity? Which personal habits do you contribute to your longevity (daily walk, special food or beverage, other habits, etc.)?

Successful Aging Centenarian CelebrationApplication & Social History

Successful Aging Centenarian Celebration
Application & Social History