Va Form 0926b - National Veterans Golden Age Games Athlete Application - 2012

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OMB Number: 2900-0759

Respondent Burden: 20 minutes

ATHLETE APPLICATION

2012 NATIONAL VETERANS GOLDEN AGE GAMES

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 20 minutes. This includes the time it will take to read instructions, gather the necessary facts and fill out the forms.

NAME (Last, First, MI)

DATE OF BIRTH

YOUR AGE AS OF

GENDER

MAY 31, 2012

MALE

FEMALE

ADDRESS (Street, City, State, Zip Code)

DAYTIME TELEPHONE

CELL PHONE NUMBER

E-MAIL ADDRESS

NUMBER (Include area code)

DIVISION:

PLEASE INDICATE T-SHIRT SIZE

PRIMARY VA MEDICAL CENTER

AMBULATORY

WHEELCHAIR

SMALL

MEDIUM

LARGE

VISUALLY IMPAIRED (Legally Blind)

TEAM COACH

TELEPHONE NUMBER OF TEAM COACH

COACH CELL PHONE NUMBER

IN CASE OF EMERGENCY, NOTIFY (Name)

PHONE NUMBER

RELATIONSHIP

NEXT OF KIN

PHONE NUMBER

RELATIONSHIP

WHEELCHAIR/SCOOTER INFORMATION: Please provide the following information about your wheelchair and/or scooter. This information can

be obtained from your Prosthetics Department.)

ARE YOU ABLE TO AMBULATE SHORT DISTANCES WITHOUT ASSISTANCE?

YES

MANUFACTURER

MODEL/MAKE

SERIAL NUMBER

TYPE

FRAME TYPE

CAMBER

WEIGHT

OVERALL WIDTH SEAT HEIGHT

SEAT WIDTH

SEAT DEPTH

POWER

MANUAL

RIGID

SCOOTER

FOLDING

FRONT WHEEL/CASTER TYPE

WHEEL

CASTER

HEIGHT

WIDTH

TIRE SIZE

BACK WHEEL/CASTER TYPE

WHEEL

CASTER

HEIGHT

WIDTH

TIRE SIZE

WHEELCHAIR/CART INSPECTED BY

TELEPHONE NUMBER

It is the athlete's responsibility to have wheelchair/scooter inspected by a VA prosthetic specialist and/or designee before arrival at the Games to insure

that your equipment is in good working order.

SERVICE DOG WILL ACCOMPANY ATHLETE?

YES

ASSISTIVE EQUIPMENT - All Athletes are encouraged to bring their own assistive equipment (shower benches, commode chairs, etc.). A limited

number and assortment of such equipment will be available on a first-come, first-served basis during the Games. Please indicate the items needed

along with style, model numbers, etc., and we will try to accommodate.

YOU MUST BRING ALL MEDICATIONS TAKEN AND ANY ASSISTIVE EQUIPMENT USED.

0926b

VA FORM

OCT 2011