0928h Volunteer Application, National Veterans Summer Sports C

OMB Number:
Respondent Burden: 5 Minutes

VOLUNTEER APPLICATION
NATIONAL VETERANS SUMMER SPORTS CLINIC
SAN DIEGO, CALIFORNIA

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.

This application must be FULLY completed. (Please type or Print)
ADDRESS (City, State and Zip Code)

NAME (Last, First, Middle Initial)

DAYTIME PHONE NUMBER
(Include area code)

EVENING PHONE NUMBER
(Include area code)

DATE OF BIRTH

PREVIOUS VOLUNTEER
(If yes, how many years

E-MAIL ADDRESS

NO
SHIRT SIZE (Check one)
SMALL
X-LARGE
MEDIUM

ARE YOU A VETERAN OF
THE ARMED FORCES

XX-LARGE

NO

LARGE
NAME OF FACILITY

IF THIS IS YOUR FIRST YEAR, WHO REFERRED
YOU TO THE SUMMER SPORTS CLINIC

DEPARTMENT OF VETERANS
AFFAIRS EMPLOYEE

YES

NO

FACILITY DIRECTOR'S NAME

National Veterans Summer

DIRECTOR'S NAME

APPROVED

YES

FACILITY ADDRESS (City, State and Zip Code)

I support the above named individuals application to participate in the
Sports Clinic. (Government Employees ONLY)
IMMEDIATE SUPERVISOR'S SIGNATURE

YES

DISAPPROVED

APPROVED
DISAPPROVED

ARE YOU ATTENDING AS (Check one)
ALTERNATE
TEAM LEADER
ACTIVITIES

HOST
OTHER
TRANSPORTATION
(Please specify)
ROOM
MEDICAL DATA SHEET - THIS MUST BE FULLY COMPLETED
NOTE: If you have ANY changes in your medical condition notify your SSC supervisor immediately.
IN CASE OF EMERGENCY, NOTIFY (This is required for you to attend the SSC)

NAME

RELATIONSHIP

DAYTIME PHONE NUMBER
(Include area code)

EVENING PHONE NUMBER
(Include area code)

MEDICAL HISTORY - (Do you have any of the following? If yes, please explain and list current medications)
ALLERGIES

NO

YES IF YES, EXPLAIN

HEART PROBLEMS

NO

YES IF YES, EXPLAIN

DIABETES

NO

YES IF YES, EXPLAIN

HIGH BLOOD PRESSURE

NO

YES IF YES, EXPLAIN

BACK PROBLEMS

NO

YES IF YES, EXPLAIN

LIFTING RESTRICTIONS

NO

YES IF YES, EXPLAIN

OTHER (Please specify)

NO

YES IF YES, EXPLAIN

LIST PREVIOUS SURGERIES

PLEASE RETURN THIS FORM BY
RETURN COMPLETED FORMS TO:

VA FORM
APR 2010

0928h

Teresa Parks (11K) [email protected]
VA Medical Center
2121 North Avenue
Grand Junction, Colorado 81501
970-263-5040 or Fax 970-244-7726
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