Form 10-7055 Application for Voluntary Service

OMB Number 2900-0090
Estimated Average Burden: 15 min.

APPLICATION FOR VOLUNTARY SERVICE
Paperwork Reduction Act and Privacy Act Information
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 15 minutes. This includes the time it will take to read instructions, gather the necessary facts and fill out the form. The information requested
on this form is solicited under the authority of 38 U.S.C. 513 and will be 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 medical centers. 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. Disclosure of the Social Security number is voluntary. The number will be used in the
identification or records.

ADDRESS (Street, City, State and Zip Code)

NAME (Last, First, Middle Initial)

TELEPHONE NUMBER

DATE
DATE
OF BIRTH

SOCIAL SECURITY NUMBER

SEX
ORGANIZATION MEMBERSHIP(S) (Unit, Post, Chapter,
if affiliated)

M

F

ASSIGNMENT

1

2

3

EXPERIENCE AND TRAINING (Special skills/Abilities)

RESTRICTIONS OR LIMITATIONS OF SERVICE (Health concerns, medications, allergies, etc.)

IN CASE OF EMERGENCY PLEASE CONTACT (Name, Relationship, Phone Number)

AVAILABILITY (Date and Time)

Monetary Waiver: I hereby waive all claims to monetary benefits for services rendered as a volunteer worker on a "without compensation
basis" for an indefinite period. I understand that this waiver applies only to remuneration (compensation) for specific services rendered in the
VA Voluntary Service (VAVS) Program and is not related to any other VA services or benefits to which I may be entitled. (NOTE: VA has
entered into this agreement by the authority of 38 U.S.C., Section 513. This agreement may be canceled by either party upon written notice.

Volunteer's Signature

Date

STUDENT VOLUNTEER PARENTAL APPROVAL

has my approval to work as a volunteer within the Department of Veterans Affairs and my
permission to receive diagnoses or emergency medical treatment if injured while volunteering.

Parent/Guardian Signature

Date

OFFICE USE ONLY
1. SUPERVISOR

2. SUPERVISOR PHONE NUMBER

3. ORIENTATIONS

4. UNIFORM

COMMENTS

VA FORM
AUG 2006

10-7055

NAME AND TITLE OF INTERVIEWER

EXISTING STOCK OF VA FORM 10-7055, FEB 1999, WILL BE USED.

DATE