0925a National Veterans Wheelchair Games Application

ATHLETE NUMBER-OFFICE USE ONLY

OMB Number:
Respondent Burden: 20 minutes

NATIONAL VETERANS WHEELCHAIR
GAMES APPLICATION

POSTMARK DEADLINE IS
. Use the enclosed envelope to return your forms. Incomplete forms
will be returned and must be resubmitted by the registration deadline.
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.
REMOVE NAME AND ADDRESS PEEL-OFF LABEL FROM THE OUTER ENVELOPE AND AFFIX HERE
↓
(mark any corrections). If you are a first-time participant and do not have a label, fill in your name and address.
SOCIAL SECURITY NO. DATE OF BIRTH
(Last 4 digits only)

NAME (Last, First, MI)

DAYTIME TELEPHONE
NO. (Include area code)

ADDRESS (Street, City, State, Zip Code)

GENDER
MALE

FEMALE

CELL TELEPHONE NO. EVENING TELEPHONE
(Include area code)
NO. (Include area code)

E-MAIL ADDRESS
ARE YOU BRINGING A SERVICE DOG?
NO
YES

WHAT BRANCH OF SERVICE WERE YOU IN?
ARE YOU A PARALYZED VETERAN OF AMERICA MEMBER?

YES

NO

YES

NO

IF YES, WHICH CHAPTER?
ARE YOU A PARALYZED VETERAN OF AMERICA ASSOCIATE MEMBER?

STATUS AND CLASSIFICATION
COMPETITOR OR
QUALIFIED COACH
(To be a qualified coach you must list below the names of five athletes you will be coaching. One qualified coach to five athletes. Note: The coach may not be one of the
five athletes.)
1

4

2

5

3
DIVISION (Check one)

OPEN

MASTERS (See page 2 for definitions)

YES

NO

NOVICE

ARE YOU A MEMBER OF A TEAM?

IF YES, TEAM NAME

TEAM COORDINATOR/LEADER

ALTERNATE TEAM CONTACT

TELEPHONE NUMBER

TELEPHONE NUMBER

E-MAIL ADDRESS

NVWG MEDICAL CLASSIFICATION (If known)
IA
IB
IC
II
GENERAL

III

IV

V

BASKETBALL

I

II

III

NOT KNOWN

RUGBY

.5

1.0

1.5

2.0

2.5

3.0

3.5

NOT KNOWN

SWIMMING

IA

IB

IC

II

III

IV

V

VI

E-MAIL ADDRESS

WHEELCHAIR INSPECTION (You must provide the following information about ALL of your competition chairs)
MAKE
TYPE

MODEL
MANUAL

HEAD
(Control)

MOUTH
(Control)

MANUAL

HEAD
(Control)

MOUTH
(Control)

MAKE
TYPE

SERIAL #

HAND
(Control) DESCRIPTION
MODEL

INSPECTED BY (Print)

SERIAL #

HAND
(Control) DESCRIPTION

SIGNATURE

You MUST have your wheelchair inspected by a VA prosthetics specialist before arrival at the Games. It is your responsibility as a competitor to
ensure that your equipment is in good working order before you depart for the Games. Coordinate through your team coordinator an "in-service" with
your VA prosthetics representative and Invacare representatives. Make sure that all chairs issued by VA are listed on your prosthetic eligibility card
by serial number, and bring your card to the Games.
VA FORM
APR 2010

0925a

Adobe LiveCycle Designer

ATHLETE NUMBER-OFFICE USE ONLY

ITINERARY INFORMATION
FLIGHT INFORMATION
DATE OF ARRIVAL

DATE OF DEPARTURE

MODE OF TRANSPORTATION TO THE GAMES
CAR

ARRIVAL

IS THIS A DIRECT
FLIGHT?

ORIGINATING AIRPORT:
ORIGINATING AIR CARRIER:

MULTIPLE CONNECTING
FLIGHTS?
CONNECTING
FLIGHT NUMBER:

CONNECTING AIRPORT(S)
CONNECTING AIR CARRIER:
ARRIVING AIR CARRIER:

BUS

TRAIN

YES

NO

YES

NO

AIRLINE

(If yes, skip to Arriving
Air Carrier)

ARRIVAL FLIGHT
NUMBER:

ARRIVAL TIME
DEPARTURE

DEPARTING FLIGHT
NUMBER

DEPARTING AIRPORT:
AIR CARRIER:
IS THIS A DIRECT
FLIGHT?

VAN

DEPARTURE TIME
YES

NO If yes, skip to Destination Airport

CONNECTING AIR CARRIER:

CONNECTING
FLIGHT NUMBER:

DESTINATION AIRPORT:
WILL YOU NEED TRANSPORTATION FROM AND TO THE AIRPORT?

YES

NO

WHO WILL BE MAKING YOUR TRAVEL ARRANGEMENTS?

CONTACT PHONE NUMBER:

NAME:

E-MAIL ADDRESS:

HOTEL RESERVATIONS

NAME (Please print)

DO YOU NEED A HOTEL ROOM?
YES

TEAM CONTACT PERSON

NO

TEAM CONTACT TELEPHONE NUMBER

CHECK-IN TIME IS 4 p.m.; CHECK-OUT TIME IS NOON. Please note that there will be a one-time per-person porterage fee of $8.
INDICATE INDIVIDUALS STAYING IN THIS ROOM
YOUR NAME:
ATHLETE
QUALIFIED COACH
GUEST:

INDICATE ROOM PREFERENCE (No guarantee):

ATHLETE
SINGLE (1 Person, 1 king)

QUALIFIED COACH

DOUBLE (2 People, 1 king)

OTHER
OTHER

DOUBLE/DOUBLE
(2 People, 2 doubles)

DO YOU NEED A ROLLAWAY BED IN THE ROOM?

YES

NO

WILL YOU BE BRINGING A PATIENT LIFT FOR THE ROOM?

YES

NO

WOULD YOU LIKE THE BATHROOM DOOR REMOVED?

YES

NO

PLEASE CHECK YOUR SMOKING PREFERENCE FOR YOUR ROOM:

SMOKING

NONSMOKING (Smoking
preference cannot be guaranteed)

All participants are encouraged to bring their own assistive equipment (shower benches, commode chairs, etc.). A limited amount
of such equipment will be available to NOVICE ATHLETES FIRST, then on a first-come, first-served basis. Please indicate the
items needed, along with style, model numbers, etc., and we will try to accommodate you. All equipment must be returned to the
Durable Medical Equipment room at the games prior to departure. Bring any medications and assistive equipment that you use.
ITEM(S) NEEDED:

TEAM AFFILIATION:
VA FORM 0925a, APR 2010, page 2

Adobe LiveCycle Designer

ATHLETE NUMBER-OFFICE USE ONLY

EVENT SELECTION
Check at least two and no more than five events. Do not schedule conflicting events! (See event schedule) Each checked box represents one event selected.
NAME (Please print)
SWIMMING (8 Classes)

AIR GUNS

BACKSTROKE
25 YARDS
HAVE YOU EVER COMPETED IN A SANCTIONED
AIR RIFLE SHOOTING EVENT? (Check one)
50 YARDS
YES
NO
100 YARDS
RIFLE
BREASTROKE
BRINGING MY OWN/TEAM RIFLE
25 YARDS
YES
NO
50 YARDS
MODEL/TYPE
100 YARDS
AIR GUNS

NEED TO BORROW AIR RIFLE
LEFT-HANDED
OTHER EQUIPMENT

RIGHT-HANDED
BRINGING
MY OWN

NEED TO
BORROW

SUPPORT STAND
REMOTE TRIGGER
MECHANISM

NOTE TO AIR GUNS & ARCHERY
PARTICIPANTS: The lending of equipment is
on a first-come first-served basis with Novice
participants having priority.

FREESTYLE
25 YARDS

II, III
IV, V, VI
IA, IB, IC
II, III
IV, V, VI
IA, IB, IC

50 YARDS

II, III

100 YARDS

IV, V, VI

HANDCYCLING (IA,-IC, II-III/IV-5) HELMETS
ARE MANDATORY (No loaner equipment
available)
MOTOR RALLY
MOTORIZED SLALOM (Hand Control)
HELMETS ARE MANDATORY
MOTORIZED SLALOM (Head [Chin] Control)
HELMETS ARE MANDATORY
MOTORIZED SLALOM (Mouth Control)
HELMETS ARE MANDATORY
NINE BALL
POWER SOCCER (Mouth Control)
POWER SOCCER (Head [Chin] Control)

BUTTERFLY
25 YARDS

IA, IB, IC, II

POWER SOCCER (Hand Control)

50 YARDS

III, IV, V, VI

QUAD RUGBY - LIMITED TO 40
COMPETITORS

INDIVIDUAL MEDLEY
75 YARDS
IA
100 YARDS

IB, IC, II, III

200 YARDS

IV, V, VI

ARCHERY
LIMITED TO 90 COMPETITORS

IA, IB, IC

OTHER
BASKETBALL - LIMITED TO 96
COMPETITORS

FIELD
CLUB (IA ONLY)

QUAD WEIGHTLIFTING
SLALOM - HELMETS ARE MANDATORY
SOFTBALL - LIMITED TO 120
COMPETITORS (No motorized wheelchairs or
scooters)
TABLE TENNIS (Single elimination)
STANDING TABLE TENNIS

RECURVE BOW

DISCUS

COMPOUND BOW

SHOT (ALL EXCEPT IA)

TRAPSHOOTING - LIMITED TO 50
COMPETITORS

STANDING ARCHERY

JAVELIN (ALL EXCEPT IA)

WEIGHTLIFTING (By body weight)

BOWLING (3 games, total pins)
RAMP (Head/mouth control)*
RAMP (Hand control)*

TRACK
HELMETS ARE MANDATORY
POWER CHAIR 200 (Mouth Control)
POWER CHAIR 200 (Head [Chin] Control)

STICK (IA, IB, IC)
HANDLEBALL (IA, IB, IC)
MANUAL (All classes)

GOLF - LIMITED TO 40 COMPETITORS

POWER CHAIR 200 (Hand Control)
POWER CHAIR RELAY (Mouth Control)
POWER CHAIR RELAY (Head [Chin] Control)
POWER CHAIR RELAY (Hand Control)

*All Ramp bowlers will be required to go through
classification

EXHIBITION
Does not count as one of the two minimum or five
maximum events.

100 METERS
200 METERS
400 METERS
800 METERS (10-Minute time limit)
1500 METERS (18-Minute time limit)

DO NOT SCHEDULE
CONFLICTING EVENTS!
CONFLICTING EVENTS:
BASKETBALL - SWIMMING
SWIMMING - SLALOM (Motor
hand/head/mouth)
POWER SOCCER - WEIGHTLIFTING (Quad)
SOFTBALL - ARCHERY - MOTOR RALLY
SOFTBALL - HAND CYCLE

NOTE Anyone participating in an event requiring a helmet must bring his or her OWN HELMET.
VA FORM 0925a, APR 2010, page 3

Adobe LiveCycle Designer