0926j Volunteer Application, National Veterans Golden Age Game

OMB Number:
Respondent Burden: 5 Minutes

VOLUNTEER APPLICATION
NATIONAL VETERANS GOLDEN AGE GAMES
PRIVACY ACT: The information requested on this form is solicited under the authority of 38 U.S.C.513 and will be used in the
selection and placement of potential volunteers in the VA Voluntary Service Program. The information you supply may be disclosed
outside VA as permitted by law; possible disclosures include those described in the 'routine uses' identified in the VA system of records
57VA125 Voluntary Service Records-VA, published in the Federal Register in accordance with the Privacy Act of 1974. The routine
uses include disclosures: in response to court subpoenas, to report apparent law violations to other Federal, State or local agencies
charged with law enforcement responsibilities, to service organizations, employers and Unemployment Compensation Offices to
confirm volunteer service, and to congressional offices at the request of the volunteer. Disclosure of the information is voluntary,
however, failure to furnish the information will hamper our ability to arrange the most satisfactory assignment for you and the
Department of Veterans Affairs.
RESPONDENT BURDEN: The Paperwork Reduction Act of 1995 requires us to notify you that this information collection is in
accordance with the clearance requirements of Section 3507 of the Paperwork Reduction Act of 1995. We may not conduct or sponsor,
and you are not required to respond to, a collection of information unless it displays a valid OMB number. We anticipate that the time
expended by all individuals who must complete this form will average 5 minutes. This includes the time it will take to read instructions,
gather the necessary facts and fill out the forms. The form is used to assist personnel of both voluntary organizations, which recruit
volunteers from their membership, and the VA in the selection, screening and placement of volunteers in the nationwide VA Voluntary
Service program. The volunteer program supplements the medical care and treatment of veteran patients in all VA facilities.
DATE ENTERED TRS

ORIENTATION COMPLETED

NAME (Last, First, MI)

DATE OF BIRTH

GENDER
MALE

ADDRESS (Street, City, State, Zip Code)

DAYTIME TELEPHONE
NUMBER (Include area code)

FEMALE

E-MAIL ADDRESS (Home & Work)

CELL PHONE NUMBER
Include area code)

WORK TELEPHONE
NUMBER (Include area code)

T-SHIRT SIZE
SMALL
X-LARGE

IN CASE OF EMERGENCY, NOTIFY

TELEPHONE NUMBER

ORGANIZATION MEMBERSHIP IF APPLICABLE (i.e. DAV, VFW, etc.)

MEDIUM

LARGE

XX-LARGE

XXX-LARGE

RELATIONSHIP
ORGANIZATION CODE (To be completed by VAVS)

DO YOU HAVE ANY PHYSICAL RESTRICTIONS OR LIMITATIONS THAT WOULD RESTRICT YOUR VOLUNTEER ACTIVITIES? (If yes, please explain)
YES

NO

PLEASE INDICATE YOUR PREFERENCE FOR VOLUNTEER ACTIVITIES
REGISTRATION

DATES

DATES

PARTICIPANT REGISTRATION

MEDICAL TRANSPORTATION

-

VOLUNTEER REGISTRATION

MEDICAL SUPPORT

-

TRANSPORTATION

-

CLINICAL

-

SET-UP

-

CLERICAL

-

WHEELCHAIR REPAIR

-

ESCORTS

-

MEMORABILIA

-

PROSTHETICS

-

MISCELLANEOUS DUTIES

-

VA FORM
APR 2010

0926j

Adobe LiveCycle Designer

EVENTS (You cannot choose more
than one event per day)

DATES

DATES

GOLF

DISCUS THROW

CHECKERS

BICYCLING

SWIMMING

SHUFFLEBOARD

HORSESHOES

TABLE TENNIS

DOMINOS

NINE-BALL

CROQUET

BOWLING

SHOT PUT

AIR RIFLE

DATES

ENTERTAINMENT

AIRPORT

-

DANCE 1

MEALS

-

DANCE 2

DIRECTIONAL GREETER

-

DANCE 3

HOTEL HOSPITALITY

-

BASS PRO TRIP

GREETER AIRPORT

-

DINNER AT IOWA STATE FAIRGROUNDS

BAGGAGE HANDLER

-

DINNER AT PRAIRIE MEADOWS CASINO

BUS TOUR GUIDE

-

KAYAKING EXHIBITION

HOSPITATLITY

COMMAND CENTER

DATES

MEDIA CENTER

DATES

DATES

COMMAND CENTER

-

MEDIA SUPPORT

-

COMMUNICATIONS/INFORMATION

-

HOMETOWN NEWS

-

DATA MANAGEMENT

-

NEWSLETTER

-

MEDIA PHOTOGRAPHY

-

CEREMONIES

DATES

AWARDS (All week)

OPENING

MEDAL CEREMONY 1

CLOSING

MEDAL CEREMONY 2
MEDAL CEREMONY 3
VCS BINGO
FINAL MEDAL CEREMONY 3

VA FORM 0926j, APR 2010, page 2

DATES

I understand and agree to abide by the following factors which have been discussed with me: volunteer rights and responsibilities,
reporting hours, fire/safety rules and regulations, reporting of special incidents, infection control, blood borne pathogens, hazard
communication, equipment and utility management, and confidentiality.
I hereby waive all claims to monetary benefits for services rendered as a volunteer worker on a "without compensation basis" for an
indefinite period. I understand that this waiver applies only to remuneration (compensation) for specific services rendered in the
Voluntary Service (VAVS) Program and is not related to any other VA services or benefits to which I may be entitled. (NOTE: VA has
entered into this agreement by the authority of 38 U.S.C., Section 513. This agreement may be cancelled by either party upon written
notice.)
FOR VA CENTRAL IOWA EMPLOYEES: I further understand that I will be granted authorized absence during my regular work
schedule (after appropriate request has been submitted to supervisor and approved). Hours worked beyond the normal workday or on
weekends will be considered strictly volunteer hours and I understand that I will not be paid overtime, compensatory time, premium pay
or differential pay.
I voluntarily and without compensation authorize pictures and/or voice recording to be made of me by or on my behalf of VA, HHV,
VCS, US military publications, and other magazines, veterans' publications, newspapers, and broadcast media, etc. while I am a
volunteer in the National Veterans Golden Age Games. I authorize any or all of the above to publicize and/or display such
photographs and recordings, or to provide such photographs and recordings to others of their choosing for display, without notice or
payment of any royalty, fee, or other compensation of any character to me for the use of my picture and/or voice. I understand that the
said pictures and/or voice recordings are intended to publicize and give recognition to the National Veterans Golden Age Games.

SIGNATURE OF EMPLOYEE VOLUNTEER

DATE

SIGNATURE OF SUPERVISOR'S APPROVAL

DATE

Please submit completed application to:

VA Central Iowa Health Care System
ATTN: Cain Davis (00)
3600 30th Street
Des Moines, Iowa 50310-5885
NVGAG Volunteer Hotline: (515) 699-5661
NVGAG Volunteer Fax: (515) 699-5875

For Volunteer Committee Only:

SIGNATURE OF NVGAG CHAIR OF VOLUNTEERS/DESIGNEE

VA FORM 0926j, APR 2010, page 3

DATE