Fillable Va Form 0926j - Volunteer Application printable pdf download

OMB Number: 2900-0759

Respondent Burden: 5 Minutes

VOLUNTEER APPLICATION

2012 NATIONAL VETERANS GOLDEN AGE GAMES

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.

DATE ENTERED VSS

ORIENTATION PACKAGE MAILED

NAME (Last, First, MI)

DATE OF BIRTH

GENDER

MALE

FEMALE

ADDRESS (Street, City, State, Zip Code)

E-MAIL ADDRESS (Home & Work)

DAYTIME TELEPHONE

CELL PHONE NUMBER

WORK TELEPHONE

IF VA EMPLOYEE, WHAT FACILITY?

NUMBER (Include area code)

Include area code)

NUMBER (Include area code)

IN CASE OF EMERGENCY, NOTIFY

TELEPHONE NUMBER

RELATIONSHIP

ORGANIZATION MEMBERSHIP IF APPLICABLE (i.e. DAV, VFW, etc.)

ORGANIZATION CODE (To be completed by VAVS)

DO YOU HAVE ANY PHYSICAL RESTRICTIONS OR LIMITATIONS THAT WOULD RESTRICT YOUR VOLUNTEER ACTIVITIES? (If yes, please

explain)

YES

PLEASE INDICATE YOUR PREFERENCE FOR VOLUNTEER ACTIVITIES

PLEASE INPUT YOUR AVAILABILITY BETWEEN MAY 30 - JUNE 6 FOR ANY CATEGORIES WITHOUT A SPECIFIC DATE LISTED

DATES

PARTICIPANT REGISTRATION

MEDICAL TRANSPORTATION

5/31/2012

VOLUNTEER REGISTRATION

MEDICAL SUPPORT

TRANSPORTATION

CLINICAL

SITE SET-UP

CLERICAL

WHEELCHAIR REPAIR

ESCORTS

MEMORABILIA

PROSTHETICS

CUSTOMER SERVICE

WALL OF FAME

5/30/2012

0926j

VA FORM

OCT 2011

Va Form 0926j - Volunteer Application

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