0929b Participant Registration Application, National Veterans

OMB Number: 2900-0759
Expiration Date: Xxx, 20XX
Respondent Burden: 35 minutes

PARTICIPANT REGISTRATION FORM
NATIONAL VETERANS CREATIVE ARTS FESTIVAL
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 35 minutes. This includes the time it will take to read instructions, gather the necessary facts and fill out the forms.
NAME (Last, First, MI)

NICKNAME

SOCIAL SECURITY NO.
(Last 4 digits only)

DATE OF BIRTH

ADDRESS (Street, City, State, Zip Code)

GENDER

CELL PHONE NUMBER
(Include area code)

TELEPHONE NUMBER 2
(Include area code)

MALE
FEMALE
FESTIVAL ROLE (If you are a non-veteran partner selected to perform in an act with a veteran in
the stage show, please fill out a Family/Friends Registration Form)

E-MAIL ADDRESS

VETERAN STAGE SHOW PARTICIPANT (Solo/group and Chorus Member performers)
VETERAN VISUAL ARTS PARTICIPANT (Artists)
STAFF CONTACT TELEPHONE VA FACILITY NAME AND ADDRESS (Street, City, State, Zip Code)
NUMBER (Include area code)

NAME OF VA STAFF CONTACT PERSON
RESPONSIBLE FOR YOUR CREATIVE ARTS
ACTIVITIES

IS THIS YOUR FIRST TIME ATTENDING THE FESTIVAL?
YES

WHAT IS YOUR VA STATUS?

NO

INPATIENT

OUTPATIENT

SERVICE CONNECTED?
YES

NO

WHAT MEDICAL EQUIPMENT WILL YOU BRING?
OXYGEN

NEBULIZER

CPAP

WALKER

WHEELCHAIR

ELECTRIC SCOOTER

OTHER MEDICAL EQUIPMENT
USE OF A WHEELCHAIR FOR
LONG DISTANCES?
YES

WHAT BRANCH OF SERVICE
WERE YOU IN?

WHICH YEARS?

NO

TO

DO YOU HAVE ANY SPECIFIC DIETARY NEEDS? (Check all that apply)
DIABETIC

REGULAR DIET

LACTOSE FREE

CARDIAC

SOFT

VEGETARIAN

OTHER

VA FORM
FEB 2014

0929b

S

M

L

XL

2X

3X

4X

5X

WHEN PLATED (Not buffet) MEALS ARE SERVED,
MY PREFERENCE IS

VEGETARIAN

MEAT

SUGAR FREE DESSERT

IN CASE OF EMERGENCY, NOTIFY (This must be filled out completely)
NAME

TELEPHONE NUMBER

SHIRT SIZE (Select one)

RELATIONSHIP TO PARTICIPANT

ADDRESS (Street, City, State and Zip Code)

LODGING IS FREE FOR VETERANS INVITED TO PARTICIPATE AT THE NATIONAL VETERANS
CREATIVE ARTS FESTIVAL, BUT EACH PARTICIPANT WILL BE ASSIGNED A ROOMMATE.
I HAVE A ROOMMATE PREFERENCE (Indicate name of roommate)
PLEASE ASSIGN ME A ROOMMATE (Roommates will be carefully selected)
IF YOU WOULD LIKE YOUR OWN ROOM, YOU WILL BE RESPONSIBLE FOR PAYING HALF OF THE ROOM COST TO THE HOTEL, WHICH IS
PER NIGHT.
I WOULD LIKE TO HAVE MY OWN ROOM AND PAY
PER NIGHT AND KNOW THAT I WILL BE RESPONSIBLE FOR
PAYING HALF OF THE ROOM COST TO THE HOTEL TO HAVE MY OWN ROOM.
IF YOU WILL BE SHARING A ROOM WITH A GUEST, YOU/YOUR GUEST WILL BE RESPONSIBLE FOR PAYING HALF OF THE ROOM COST TO
THE HOTEL ON ANY NIGHTS THE GUEST IS NOT STAYING WITH YOU,
I WOULD LIKE A ROOM TO SHARE WITH MY GUEST, I WILL PAY
PER NIGHT TO THE HOTEL ON ANY NIGHTS I DON'T
HAVE A PAYING GUEST. MY GUEST WILL STAY WITH ME THE FOLLOWING NIGHTS AND WILL PAY HALF OF THE ROOM COST
(
).
NOTE: Performers will arrive on Monday, 10/21 and artists will arrive on Wednesday, 10/23. Everyone will depart on Monday, 10/28.
PLEASE CHECK THE NIGHTS YOU ARE PLANNING TO STAY.
ROOM TYPE (Check one)
ONE KING BED

TWO QUEEN BEDS

ROOM REQUIREMENTS
I WILL NEED A HANDICAPPED ACCESSIBLE ROOM
OTHER ROOM NEEDS
I UNDERSTAND THAT I MUST PRESENT A CREDIT CARD UPON CHECK-IN TO PAY FOR INCIDENTALS (room service, in-room movies, telephone
calls, internet service) THAT I MIGHT INCUR DURING THE WEEK. I ALSO UNDERSTAND THAT I WILL BE RESPONSIBLE FOR PAYMENT OF ANY
FINE(S) INCURRED.
THE GRAND SIERRA HOTEL WILL CHARGE A $200 FINE FOR SMOKING IN A NON-SMOKING SLEEPING ROOM.
THE GRAND SIERRA HOTEL HAS AN EARLY CHECK-OUT FEE OF $50, EXCEPT IN THE CASE OF ILLNESS OR AN EMERGENCY SITUATION.
SUBMIT COMPLETED PARTICIPANT REGISTRATION FORM NO LATER THAN

Stephanie Torian
Host Site Coordinator (05/Vol)
VA Sierra Nevada Health Care System
975 Kirman Avenue
Reno, NV 89502
Phone: (775) 328-1411 / Fax: (775) 337-2276
[email protected]

VA FORM 0929b, FEB 2014, page 2

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