Va Form 0927d - Media And News Release Questionnaire Page 2

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8. HOW MANY PAST YEARS HAVE YOU
9. DO YOU WANT US TO PREPARE A NEWS RELEASE
PARTICIPATED IN THE NATIONAL VETERANS TEE
ABOUT YOUR PARTICIPATION IN THIS EVENT?
TOURNAMENT?
YES
NO
10. IF YOU MARKED "YES" TO A NEWS RELEASE IN QUESTION 9, PLEASE PROVIDE THE FOLLOWING
INFORMATION.
REQUEST FOR AND AUTHORIZATION TO RELEASE MEDICAL RECORDS OR HEALTH INFORMATION: I
REQUEST AND AUTHORIZE THE DEPARTMENT OF VETERANS AFFAIRS TO RELEASE THE MEDICAL
INFORMATION CONTAINED ON THIS FORM FOR VA MEDIA PURPOSES. (If you checked this block, please check
one of the boxes below.)
I GIVE MY PERMISSION FOR MY PHONE NUMBER TO BE INCLUDED IN MY NEWS RELEASE POSTED
ON THE EVENTS' WEBSITE
I DO NOT WANT MY PHONE NUMBER LISTED ON MY NEWS RELEASE
11. PLEASE NOTE: WHETHER OR NOT YOU WANT A NEWS RELEASE, TOURNAMENT RESULTS WILL BE
POSTED ON THE TOURNAMENT WEBSITE BY PARTICIPANT NAME UNLESS YOU CHECK THE "NO" BOX HERE.
NO (Results will not be posted; sign below)
12. YOUR QUOTE: HOW DO YOU FEEL ABOUT THIS EVENT, WHY IS IT BENEFICIAL, AND WHAT WOULD YOU
TELL OTHER VETERANS ABOUT IT? (Quotes are used for newsletter stories, participant profiles, speeches, and other public
relations activities.)
SIGNATURE (You must sign here so we can comply with your
DATE SIGNED
wishes)
VA FORM 0927d, DEC 2010, page 2

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