Va Form 0926c - National Veterans Golden Age Games Media And News Release Questionnaire - 2012
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1
2ATHLETE NUMBER-OFFICE USE ONLY
OMB Number: 2900-0759
Respondent Burden: 20 minutes
MEDIA AND NEWS RELEASE
QUESTIONNAIRE
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.
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.
All athletes must complete questions 1-12, whether or not you wish to have a news release. If you would like a news release posted on
the Games' website about your participation this year, you must fill out this form completely. Our Hometown News program promotes
publicity about the Games by posting an individual news release for every veteran who wants one on the Games' website during the
week of the Games. The releases may be found on the Games website, In order to prepare
your news release, we must have all needed information in advance. We cannot gather this information during the Games. If you have
any questions, please call VA Public Affairs at (314) 289-6393.
NAME (Last, First, MI)
TEAM NAME (If applicable)
DATE OF BIRTH
E-MAIL ADDRESS
1. PLEASE CONFIRM YOUR BRANCH OF SERVICE
AIR FORCE
ARMY
COAST GUARD
MARINE CORPS
NAVY
NATIONAL GUARD
OTHER (Please specify)
2. IF YOU ARE A PEACETIME VETERAN, WHERE AND WHEN DID YOU SERVE?
3. DID YOU SERVE IN COMBAT IN ANY OF THE FOLLOWING CONFLICTS?
WWII
KOREA
VIETNAM
THE GULF WAR
IRAQ
AFGHANISTAN
OTHER (Please specify)
4. WERE YOU EVER HELD AS A POW? (If yes, where)
YES
NO
5. ARE YOU A VIETNAM ERA (NONCOMBAT) VETERAN?
YES
NO
6. OF WHICH VETERANS SERVICE ORGANIZATIONS ARE YOU A MEMBER?
PVA
DAV
VFW
AMERICAN LEGION
AMVETS
MOPH
OTHER
7. WHAT IS YOUR PRIMARY VA MEDICAL CENTER (City, State)
8. PLEASE CHECK WHICH DIVISION YOU WILL COMPETE IN
AMBULATORY
WHEELCHAIR
VISUALLY IMPAIRED
9. HOW MANY PAST YEARS HAVE YOU PARTICIPATED IN THE
10. DO YOU WANT US TO PREPARE A NEWS RELEASE ABOUT YOUR
NATIONAL VETERANS GOLDEN AGE GAMES?
PARTICIPATION IN THIS EVENT?
YES
NO
11. IF YOU MARKED "YES" TO A NEWS RELEASE IN QUESTION 10, 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.
I GIVE MY PERMISSION FOR MY PHONE NUMBER TO BE INCLUDED IN MY NEWS RELEASE POSTED ON THE GAMES' WEBSITE
I DO NOT WANT MY PHONE NUMBER LISTED ON MY NEWS RELEASE
12. PLEASE NOTE: WHETHER OR NOT YOU WANT A NEWS RELEASE, ALL EVENT RESULTS WILL BE POSTED ON THE GAMES WEBSITE BY
PARTICIPANT NAME UNLESS YOU CHECK THE "NO" BOX HERE.
NO (Results will not be posted; sign on next page)
0926c
VA FORM
OCT 2011
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