Va Form 0928b - National Veterans Summer Sports Clinic Registration Application - 2012
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1OMB Number: 2900-0759
Respondent Burden: 20 minutes
REGISTRATION APPLICATION
2012 NATIONAL VETERANS SUMMER SPORTS CLINIC
DEADLINE: JUNE 1, 2012
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.
SHIRT SIZE
NAME (Last, First, MI)
SOCIAL SECURITY NO.
DATE OF BIRTH
MALE
(Last 4 digits only)
S
L
2X
FEMALE
M
XL
3X
ADDRESS (Street, City, State, Zip Code)
DAYTIME TELEPHONE
EVENING TELEPHONE
E-MAIL ADDRESS
NUMBER (Include area code)
NUMBER
DO YOU RECEIVE YOUR CARE AT A
PLEASE PRINT THE NAME OF THE FACILITY YOU
DO YOU GET YOUR PHYSICAL DONE AT THE
RECEIVE CARE AT
VAMC
(OR)
CBOC
VAMC
(OR)
PRIVATE PHYSICIAN
WHAT BRANCH OF SERVICE WERE YOU IN? YEARS IN SERVICE
WHAT SERVICE ORGANIZATIONS DO YOU BELONG TO?
HAVE YOU ATTENDED THE SUMMER SPORTS CLINIC BEFORE?
(If Yes, which years?)
YES
NO
ARE YOU ATTENDING WITH A TEAM?
(If Yes, coach's name)
YES
NO
HAVE YOU COMPETED IN AN ORGANIZED ADAPTIVE/DISABLED
YES
NO
(If Yes, coach's name)
SPORTS EVENT?
HAVE YOU PARTICIPATED IN ANY OF THE OTHER VA NATIONAL
YES
NO
NVWCG
NDVWSC
NVCAF
NVGAG
NVTT
PROGRAMS? (Mark all that you have attended)
INPATIENT
OUTPATIENT
WHAT IS YOUR VA STATUS?
IS YOUR DISABILITY SERVICE CONNECTED?
YES
NO
The National Veterans Summer Sports Clinic is a VA sponsored event. The clinic is an outreach of VISN 22 and the San Diego Healthcare System.
Compliance with VA regulations and policies is mandatory at this event for all participants. Bringing weapons, unprescribed drugs or
paraphernalia, unexcused non-participation, exhibiting disruptive or abusive behavior and harassment of others in any form, will not be
tolerated and may result in immediate expulsion from this event and will effect future participation.
The Department of Veterans Affairs encourages a safe environment for all attendees. These rules exist for the safety of everyone involved in the
clinic.
ATHLETE SIGNATURE
IN CASE OF EMERGENCY, NOTIFY (This must be filled out completely)
ADDRESS (Street, City, State and Zip Code)
NAME
TELEPHONE NUMBER
RELATIONSHIP TO PATIENT
NOTE: Registration Deadline is June 1, 2012. There will be a $50 late fee for any applications postmarked past the deadline. Applications which
are not completely and correctly filled out will be returned to you. They must be corrected or completed and resubmitted by the June 15, 2012
deadline. Please do not fold or staple the application.
For any questions regarding this application, please call Tristan Heaton at (858) 642-6426.
0928b
VA FORM
Page 1 of 1
MAR 2012
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