Va Form 0927b - Participant Registration Application Page 2

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DO YOU NEED A SPECIALIZED GOLF CART TO PLAY?
YES
NO
IF "YES"
SINGLE RIDER
PARA RIDER
YOUR AVERAGE GOLF SCORE FOR NINE HOLES
HANDICAP
IF YOU DO NOT PLAY AN ENTIRE ROUND ON EACH HOLE, DO YOU GENERALLY SHOOT
PAR
BOGEY
DOUBLE BOGEY
TRIPLE BOGEY
HIGHER
YES
NO
(If "Yes", Name:
ARE YOU BRINGING A GOLF BUDDY
All golf buddies must fill out a volunteer form. A volunteer form is attached to this application. If additional forms are needed
contact Sarah Steen, Volunteer Coordinator, at 319-338-0581, ext. 3607; or e-mail to: sarah.steen@va.gov.
NAME OF GOLF BUDDY PREFERENCE, IF THERE IS A VOLUNTEER YOU PREFER
WEDNESDAY ACTIVITIES INCLUDE GOLF INSTRUCTION FOR 1/2 OF THE DAY AND THE OTHER 1/2 OF THE DAY
YOU WILL HAVE A CHOICE OF THE FOLLOWING ACTIVITIES (Rank them 1 - 4)
GOLFING
KAYAKING
BOWLING
HORSEBACK RIDING
ROOMMATE PREFERENCE (Select one)
NAME
RELATIONSHIP
PAID COMPANION
FAMILY VOLUNTEER
VETERAN PARTICIPANT
ROOM ARRANGEMENTS
IS A (HANDICAP) ACCESSIBLE ROOM MEDICALLY REQUIRED? (If yes, why?)
YES
NO
ARE SEPARATE BEDS REQUIRED?
YES
NO
ARE YOU A SMOKER?
YES
NO
PLEASE LIST ANY DIETARY RESTRICTIONS YOU HAVE
ANY OTHER PERTINENT INFORMATION?
Early arrival or late departure room rates will be at the participants or volunteers own expense. Please let us know if you
intend to come early or depart late and require additional room nights. List here the nights or call Lori Montag at
319-358-5962.
(A PAID COMPANION NEEDS TO FILL OUT A COMPANION REGISTRATION FORM.)
VA FORM 0927b, JAN 2013, page 2

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