Cumberland Centenarian Recognition Form

Please complete the following form to nominate a Cumberland County resident turning 100 years old to receive our Cumberland Centenarian Recognition. For help completing the form or any questions you may have, please contact the Aging & Community Services Office at 717.240.6110 or email aging@cumberlandcountypa.gov.

Please answer all questions with detail so we can properly recognize your centenarian.

Centenarian Information

1. Full Name*

2. Birth Date*

3. Current Address*

4. Place of Birth (town/city)

5. Spouse's Name

6. Marital Status

Single Married Widowed Divorced Separated

7. If married, how many years?

8. Number of children

9. Number of grandchildren

10. Number of great grandchildren

11. Number of great-great grandchildren

12. Hobbies and interests*

13. Primary career*

14. Places they have worked

15. Clubs, organizations, groups they belong to

16. Interesting personal facts and stories

17. Any secrets to living a long life?

18. Their biggest accomplishment

19. Things they are known for

Contact Person Information

20. Name*

21. Phone Number*

22. Email*

23. Relationship to centenarian