Va Form 0926h - National Veterans Golden Age Games Non-Athlete Application - 2012
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1OMB Number: 2900-0759
Respondent Burden: 20 minutes
NON-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)
DAYTIME TELEPHONE
CELL PHONE NUMBER
NUMBER (Include area code)
ADDRESS (Street, City, State, Zip Code)
E-MAIL ADDRESS
IF REPRESENTING A VA MEDICAL CENTER, WHICH ONE?
PLEASE CHECK ONLY ONE
DO YOU USE AN ASSISTIVE DEVICE?
COACH
NATIONAL OFFICIAL
SUPPORT STAFF
SCOOTER
MANUAL
POWER
WHEELCHAIR
WHEELCHAIR
FAMILY/SIGNIFICANT OTHER
TRAVELING VOLUNTEER
WALKER
IN CASE OF EMERGENCY, NOTIFY (Name)
TELEPHONE NUMBER
RELATIONSHIP
NEXT OF KIN
TELEPHONE NUMBER
RELATIONSHIP
FOR COACHES ONLY, DOES YOUR TEAM HAVE A NAME? (If yes, what is the name of the team)
YES
NO
PLEASE LIST YOUR TEAM MEMBERS
Release of Picture/Information: I voluntarily and without compensation authorize photograph(s), video(s), and voice recording(s) to be made of me by
or on behalf of the Department of Veterans Affairs (VA), the Veterans Canteen Service (VCS), Help Hospitalized Veterans (HHV), US military
publications, community media outlets, etc., while I am attending the 26
National Veterans Golden Age Games. I authorize any or all of the above to
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publicize and/or display such photographs and recordings, or to provide such photographs and recordings to others of their choosing for display,
without notice or payment of any royalty, fee, or other compensation of any character to me for the use of my picture and/or voice. I understand that
the said picture(s) and/or voice recording(s) are intended to publicize and give recognition to the National Veterans Golden Age Games. Also, I
authorize storage of my registration and event data in the electronic media.
SIGNATURE
DATE
0926h
VA FORM
OCT 2011
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