Successful Aging 2025 Centenarian Celebration
Application & Social History

This form must be submitted by Tuesday, August 12.

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 Tuesday, September 9 at 5 p.m. in the Vola Lawson Lobby of Alexandria City Hall (301 King Street).

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* 1. Date of submission

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CENTENARIAN INFORMATION

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* 2. Centenarian's name

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

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* 4. Centenarian's age

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* 5. Year of birth

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* 6. Centenarian's email

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* 7. Centenarian's phone number

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* 8. Centenarian's mailing address for certificate *

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

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