0927b Participant Registration Application, National Veterans

OMB Number:
Respondent Burden: 20 minutes

PARTICIPANT REGISTRATION APPLICATION
NATIONAL VETERANS TEE TOURNAMENT
DEADLINE:
PRIVACY ACT: VA is asking you to provide the information on this form under USC, Chapter 5, Section 521 and Chapter 17,
Section 1710. VA may disclose the information that you put on this form as permitted by law. VA may make a "routine use"
disclosure of the information as outlined in the Privacy Act systems of records notices identified as 121VA19 “National Patient
Databases - VA”. Providing the requested information is voluntary. However, you will not be able to participate in the event without
furnishing this information.
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 application will average 20 minutes. This includes the time it will take to read
instructions, gather the necessary facts and fill out the forms.
NAME (Last, First, MI)

SOCIAL SECURITY DATE OF BIRTH
NO. (Last 4 digits only)

GENDER
MALE

ADDRESS (Street, City, State, Zip Code,
and County)

NAME TAG PREFERENCE

DAYTIME TELEPHONE
NUMBER (Include area code)

EVENING TELEPHONE
NUMBER (Include area code)

PRIMARY VA MEDICAL CENTER
(City & State)

E-MAIL ADDRESS

PLEASE INDICATE YOUR T-SHIRT SIZE
SMALL
MEDIUM
LARGE
XL

XXL

WHAT BRANCH OF SERVICE WERE YOU IN?
AIR FORCE
ARMY
MARINE CORPS

XXXL

NAVY

FEMALE

OTHER

COAST GUARD

OTHER

INDICATE ANY NEED FOR SPECIAL TRAVEL ASSISTANCE UPON ARRIVAL OR DEPARTURE. ALL PARTICIPANTS
ARE ENCOURAGED TO BRING THEIR OWN ASSISTIVE EQUIPMENT (shower benches, commode chairs, etc.). ALL
PARTICIPANTS MUST BRING THEIR OWN MEDICATIONS.

WILL YOU BE ACCOMPANIED BY A TRAINED/CERTIFIED ASSISTANCE DOG?

YES

NO

WILL YOU REQUIRE A DOG SITTER?
PLEASE LIST ANY DIETARY RESTRICTIONS YOU HAVE

YES

NO

ARRIVAL DATE AND ESTIMATED ARRIVAL TIME

TRAVEL MODE (Select one)
OWN VEHICLE

IF YOU ARE NOT PLANNING TO STAY AT THE EVENT
HOTEL(S), INDICATED WHERE YOU WILL BE STAYING.
(Include: Name, Street, City, State, Zip Code, and Phone Number)

AIR

BUS

VANPOOL

THERE ARE A VARIETY OF ACTIVITIES IN WHICH
YOU CAN PARTICIPATE. PLEASE RANK YOUR
CHOICES BELOW. (1 - 5)
GOLFING
HORSESHOES

KAYAKING

BOWLING

BAG TOSS

IN ORDER TO HELP US ASSIGN YOU TO THE OPTIMAL GOLF GROUP AND PROVIDE ADEQUATE INSTRUCTION
FOR YOUR GOLF NEEDS, PLEASE LET US KNOW THE FOLLOWING
ARE YOU

RIGHT-HANDED

HAVE YOU EVER GOLFED BEFORE?

YES

NO

ARE YOU BRINGING YOUR OWN GOLF CLUBS?

YES

NO

VA FORM
APR 2010

0927b

LEFT-HANDED

(If "No", skip the next two questions

Adobe LiveCycle Designer

YOUR AVERAGE GOLF SCORE FOR NINE HOLES
IF YOU DO NOT PLAY AN ENTIRE ROUND ON
EACH HOLE, DO YOU GENERALLY SHOOT

HANDICAP
PAR

BOGEY

TRIPLE BOGEY

HIGHER

YES

ARE YOU BRINGING A GOLF BUDDY

NO

DOUBLE BOGEY

(If "Yes", Name:

ALL GOLF BUDDIES MUST FILL OUT A VOLUNTEER FORM. A VOLUNTEER FORM IS ATTACHED TO THIS
APPLICATIONS. IF ADDITIONAL FORMS ARE NEEDED CONTACT
NAME OF GOLF BUDDY PREFERENCE, IF THERE IS A VOLUNTEER YOU PREFER
ROOMMATE PREFERENCE (Select one)
PAID COMPANION

NAME

VETERAN PARTICIPANT

ADDRESS (Street, City, State, Zip Code,
and County)

VOLUNTEER

ROOM ARRANGEMENTS
IS A MAIN FLOOR ROOM REQUIRED?
ARE SEPARATE BEDS REQUIRED?

YES
YES

NO
NO

ARE YOU A SMOKER?

YES

NO

ANY OTHER PERTINENT INFORMATION?

(A PAID COMPANION NEEDS TO FILL OUT A COMPANION REGISTRATION FORM.)

VA FORM 0927b, APRIL 2010, page 2