Va Form 0928a - National Veterans Summer Sports Clinic Va Form Mar 2012 0928a Registration Checklist - 2012

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OMB Number: 2900-0759
Respondent Burden: 20 minutes
2012 NATIONAL VETERANS
SUMMER SPORTS CLINIC
REGISTRATION CHECKLIST
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.
You must completely and correctly fill out the enclosed packet, or your application will not be processed.
Registration deadline is June 1, 2012. A $50 late fee will be charged to any application
received after June 1, 2012.
Applications postmarked after June 15, 2012 will not be accepted.
Please do not fold or staple application.
YOU MUST INCLUDE THE FOLLOWING FORMS FILLED OUT COMPLETELY. DO NOT SEND APPLICATION
WITHOUT ALL OF THE FOLLOWING:
REGISTRATION CHECKLIST (VA Form 0928a)
REGISTRATION APPLICATION (VA Form 0928b) (Filled out by participant)
GENERAL MEDICAL/PHYSICAL EXAM FORM (VA Form 0928c) (Must be filled out completely and signed by
examining clinician) (Make sure problem list, EKG for age 40 and over, and current medications list is included in
addition to the two medical pages)
MEDIA AND NEWS RELEASE QUESTIONNAIRE (VA Form 0928d)
APPLICATION FOR HEALTH BENEFITS (VA Form 1010EZ) (For Veterans not registered with VA)
Please allow four weeks for your application to be processed. When accepted, you will receive
information regarding hotel and flight reservations and ground transportation.
To avoid confusion and possible loss of funds, please do not make any travel or lodging reservations
until you have received the letter notifying you that your application has been accepted.
All applications and forms must be mailed to:
Tristan Heaton (00SSC)SV
National Veterans Summer Sports Clinic
VA San Diego HCS
3350 La Jolla Village Dr.
San Diego, CA 92161
0928a
VA FORM
MAR 2012

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