Fillable Va Form 0927f - Volunteer Registration Application printable pdf download

OMB Number: 2900-0759

Respondent Burden: 5 minutes

VOLUNTEER REGISTRATION APPLICATION

NATIONAL VETERANS TEE TOURNAMENT

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.

PLEASE PRINT - IF YOU MUST CANCEL, PLEASE CONTACT US AT:

NAME (Last, First, MI)

DATE OF BIRTH

NAME TAG PREFERENCE

ADDRESS (Street, City, State, Zip Code, and County)

HOME TELEPHONE

WORK TELEPHONE

CELL TELEPHONE NUMBER

NUMBER (Include area code)

(Include area code)

PLEASE INDICATE YOUR T-SHIRT SIZE

E-MAIL ADDRESS

GENDER

SMALL

MEDIUM

LARGE

MALE

FEMALE

XXL

XXXL

IF YOU ARE A VA EMPLOYEE VOLUNTEER,

SERVICE/DEPARTMENT

ROUTING SYMBOL

PLEASE LIST YOUR VA MEDICAL FACILITY

TELEPHONE NUMBER (Include area code)

SUPERVISORS SIGNATURE (VA employee volunteers need

to have authorized absence approved by their supervisor)

IN CASE OF AN EMERGENCY, CONTACT:

TELEPHONE NUMBER

RELATIONSHIP

VOLUNTEERS NEEDING LODGING: If you live outside the direct commuting area (25 miles), of the NVTEE Tournament Event,

and need to stay at the hotel, please indicate the nights you will need a room. All volunteers will be assigned two-to-a-room. A

Volunteer who stays at the hotel will be required to volunteer all day as assigned by the Volunteer Coordinator.

ROOM NEEDED

ROOM PREFERENCE

MONDAY

TUESDAY

WEDNESDAY

THURSDAY

SMOKING

NON-SMOKING

ESTIMATED ARRIVAL DATE/TIME

A.M.

P.M.

NAME OF ROOMMATE PREFERENCE

VOLUNTEER

COMPETITOR

TRANSPORTAION

WILL YOU USE YOUR OWN VEHICLE TO TRAVEL BACK AND FORTH TO THE EVENT VENUES?

YES

MEALS (Check each meal you plan on eating with us)

DO YOU HAVE SPECIAL DIETARY NEEDS? (If yes, describe)

YES

BREAKFAST

LUNCH

DINNER

MONDAY

TUESDAY

WEDNESDAY

THURSDAY

FRIDAY

0927f

VA FORM

FEB 2012

Va Form 0927f - Volunteer Registration Application

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