0924n Cross Country Ski Instructor Personnel Application, Nati

OMB Number: 2900-0759
Expiration Date: Xxx, 20XX
Respondent Burden: 5 minutes

CROSS COUNTRY SKI INSTRUCTOR
PERSONNEL APPLICATION

NATIONAL DISABLED VETERANS WINTER SPORTS CLINIC
SNOWMASS VILLAGE AT ASPEN, COLORADO

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)
NAME (Last, First, Middle Initial)

DAYTIME PHONE NUMBER
(Include area code)

ADDRESS (City, State and Zip Code)

CELL PHONE NUMBER
(Include area code)

DATE OF BIRTH

E-MAIL ADDRESS

PREVIOUS VOLUNTEER
(If yes, how many years)
NO

OCCUPATION

DEPARTMENT OF VETERANS IF THIS IS YOUR FIRST YEAR, WHO REFERRED
AFFAIRS EMPLOYEE
YOU TO THE WINTER SPORTS CLINIC
YES

ARE YOU CAPABLE OF BEING
A PRIMARY INSTRUCTOR

NO

YES

FACILITY ADDRESS (City, State and Zip Code)

NAME OF FACILITY

YES

NO

PSIA ADAPTIVE CERTIFICATION?
LEVEL I

NONE

LEVEL II

FACILITY DIRECTOR'S NAME

CERTIFICATION IS IN

LEVEL III
CAN YOU TEETHER A TEACHING PREFERENCE (1st & 2nd preference)
BI-SKI

REQUEST FOR PREVIOUS STUDENT'S

4 TRACKER

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

APPROVED

National Disabled Veterans

DIRECTOR'S NAME

APPROVED

DISAPPROVED
LIST YEARS OF TEACHING AS A
PRIMARY INSTRUCTOR
WHERE ARE YOU CURRENTLY
TEACHING ADAPTIVE SKIING?

SKI INFORMATION
DO YOU TEACH
FULL TIME

ABILITY LEVEL: B=BEGINNER; I=INTERMEDIATE; A=ADVANCED
SKI TYPE
SNOWSHOE

VA FORM
FEB 2014

0924n

YEARS OF
EXPERIENCE

DISAPPROVED

ABILITY LEVEL

LEVEL OF TEACHING ABILITY
(Please be accurate)
HOW MANY ADAPTIVE LESSONS IS THE WSC THE ONLY
TIME YOU TEACH?
DO YOU TEACH A WEEK?

PART TIME

YES

NO

(SIT-SKI AND SNOWSHOE PERTAIN TO NORDIC INSTRUCTORS)
SKI TYPE
SIT-SKI

YEARS OF
EXPERIENCE

ABILITY LEVEL

PLEASE LIST ANYTHING YOU DO NOT WANT TO TEACH OR ARE UNCOMFORTABLE TEACHING
IF YOU ARE A BUDDY, PLEASE FILL OUT THE ABOVE
INFORMATION AND WRITE IN THE FOLLOWING
SPACE THAT YOU ARE A BUDDY/ASSISTANT

PLEASE LIST A POC WHO CAN CONFIRM YOUR
TEACHING EXPERIENCE (Name)

POC TELEPHONE NUMBER
(Include area code)

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

RELATIONSHIP

DAYTIME PHONE NUMBER

CELL PHONE NUMBER

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

HEIGHT

(inches)

(pounds)

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

MALE

FEMALE

LIST PREVIOUS SURGERIES

PLEASE RETURN THIS FORM BY
RETURN COMPLETED FORMS TO:

VA FORM 0924n, FEB 2014, page 2

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