Form Center

By signing in or creating an account , some fields will auto-populate with your information.

100 Birthday Club

Sign in to Save Progress

Steps

  1. 1. Step One (current) This section is complete This section is incomplete
  2. 2. Honoree Information: This section is complete This section is incomplete
  3. 3. Contact Information: This section is complete This section is incomplete

  • Step One

    2. 100 Birthday Club

      VILLAGE OF ROMEOVILLE
    4. Description:

      The village would like to honor Romeoville residents who are 100 years old or older! Please fill out this questionnaire so that we know who we should be honoring and how to contact them.

      Honors will include:

      • A recognition certificate
      • A 100 Birthday Club pin
      • Recognition on the 100th Birthday Club webpage for one month

      For questions please email Dawn Caldwell at dcaldwell@romeoville.org

    Honoree Information:

    Contact Information:

    2. The contact information collected below should be for the person being honored or whoever the best person would be to coordinate a ceremony or gift pickup/drop off with.
      9. Leave This Blank:

    11. This field is not part of the form submission.

    * indicates a required field