0927f Volunteer Registration Application, National Veterans Te

OMB Number:
Respondent Burden: 5 minutes

VOLUNTEER REGISTRATION APPLICATION
NATIONAL VETERANS TEE TOURNAMENT
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.
PLEASE PRINT - IF YOU MUST CANCEL, PLEASE CONTACT US AT:

NAME (Last, First, MI)

DATE OF BIRTH

NAME TAG PREFERENCE

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

DAYTIME TELEPHONE
EVENING PHONE
CELL TELEPHONE NUMBER
NUMBER (Include area code) NUMBER (Include area code) (Include area code)

PLEASE INDICATE YOUR T-SHIRT SIZE

E-MAIL ADDRESS

MEDIUM

LARGE

XL

XXL

GENDER
MALE

XXXL

IF YOU ARE A VA EMPLOYEE VOLUNTEER,
PLEASE LIST YOUR VA MEDICAL FACILITY

SERVICE/DEPARTMENT

TELEPHONE NUMBER (Include area code)

SUPERVISORS SIGNATURE (VA employee volunteers need
to have authorized absence approved by their supervisor)

IN CASE OF AN EMERGENCY, CONTACT:

TELEPHONE NUMBER

FEMALE

ROUTING SYMBOL

RELATIONSHIP

VOLUNTEERS NEEDING LODGING: If you live outside the Tournament area and need to stay at the hotel(s), please indicate the
nights you need a room. All volunteers will be assigned two-to-a-room. If you request a single room, a fee of $35.00 per night, per
person is required to cover the full cost and is due with this application. Payment cannot be made the day of registration or mailed in
after the Tournament.
ROOM NEEDED
MONDAY

ESTIMATED ARRIVAL DATE/TIME
TUESDAY

WEDNESDAY

THURSDAY

A.M.

/

P.M.

NAME OF ROOMMATE PREFERENCE
VOLUNTEER

COMPANION*

COMPETITOR

*NOTE: The Participant/Companion Fees form needs to be completed if the roommate is a companion who is not also a volunteer.
ROOM ARRANGEMENTS
ARE SEPARATE BEDS REQUIRED?

YES

NO

DO YOU HAVE SPECIAL DIETARY NEEDS? (If yes, describe)

YES

NO

MEALS (Check each meal you plan on eating with us)
BREAKFAST

LUNCH

DINNER

MONDAY
TUESDAY
WEDNESDAY
THURSDAY
FRIDAY
VA FORM
APR 2010

0927f

Adobe LiveCycle Designer

ACTIVITY SIGN UP
1. Check the Preference column for the day/time of each event that you would like to volunteer for.
2. If you chose more than one event on the same day/time, RANK each event by placing 1 = Most Desirable up to 4 = Least Desirable
in the Preference column.
GOLF BUDDY (Note skill level)
DAY

DATE

YES

HAVE YOU EVER GOLFED BEFORE?

PREFERENCE/
RANK

TIME

NO

HOW MANY ROUNDS OF GOLF PER YEAR?
GOLF EXPERIENCE

IS THERE A PARTICIPANT YOU WOULD PREFER TO BE A GOLF
BUDDY FOR?
HAVE YOU EVER WORKED WITH ANYONE WITH DISABILITIES?
(If "yes", please specify)

USGA HANDICAP
INSTRUCTOR EXPERIENCE

YES

NO

RECREATIONAL GOLFER
HORSESHOES
DAY

BOWLING
DATE

TIME

PREFERENCE/
RANK

BAG TOSS
DAY

DATE

TIME

PREFERENCE/
RANK

DATE

PREFERENCE/
RANK

DATE

DATE

VA FORM 0927f, APRIL 2010, page 2

DAY

DATE

TIME

PREFERENCE/
RANK

DAY

DATE

TIME

PREFERENCE/
RANK

TIME

PREFERENCE/
RANK

ENTERTAINMENT (Casino Night)
TIME

PREFERENCE/
RANK

REGISTRATION (Check participants in/help with luggage to room)
DAY

TIME

NURSES
MEALS
BREAKFAST LUNCH DINNER

DOGSITTING (Only 3 needed)
DAY

DATE

KAYAKING

FOOD (Serve and clean-up (help veterans))
DAY

DAY

TIME

PREFERENCE/
RANK

DAY

DATE

TRANSPORTATION (Drive vehicles, assist with boarding/unloading veterans)
PREFERENCE/
DATE
TIME
DAY
RANK