0925d Voluntary Service Application, National Veterans Wheelch

OMB Number:
Respondent Burden: 5 minutes

VOLUNTARY SERVICE APPLICATION
NATIONAL VETERANS WHEELCHAIR GAMES
PRIVACY ACT: The information requested on this form is solicited under the authority of 38 U.S.C.513 and will be used in the selection and placement of
potential volunteers in the VA Voluntary Service Program. 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.
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 form will
average 5 minutes. This includes the time it will take to read instructions, gather the necessary facts and fill out the forms. The form is 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 facilities.

This application must be FULLY completed. (Please type or Print)
NAME (Last, First, Middle Initial)

ADDRESS (City, State and Zip Code)

DATE OF BIRTH

DAYTIME PHONE NUMBER
(Include area code)

EVENING PHONE NUMBER
(Include area code)

E-MAIL ADDRESS

DATE

GENDER

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

MALE

FEMALE

ASSIGNMENT PREFERENCES
1.

2.

3.

EXPERIENCE AND TRAINING (Special Skills/Abilities) (The Applicant is volunteering for the NVWCG)

RESTRICTIONS OR LIMITATIONS OF SERVICE (Health, Medications, Allergies, etc.)

IN CASE OF EMERGENCY, NOTIFY
NAME

RELATIONSHIP

AVAILABILITY (Dates and Times)

TELEPHONE NUMBER
(Include area code)

HAVE YOU EVER BEEN CONVICTED
OF A FELONY OFFENSE?
YES
NO

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 cancelled 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
2. Supervisor Telephone Number:

1. Supervisor:
3. Orientation(s):

4. Uniform:

FINGERPRINTING REQUIRED
YES
VA FORM
APR 2010

NAME AND TITLE OF INTERVIEWER

DATE

NO

0925d

Adobe LiveCycle Designer

SIGN UP EARLY!
Volunteer positions are on a first come, first served basis.
T-SHIRT SIZE (Check one)
SMALL

MEDIUM

LARGE

X-LARGE

XX-LARGE

XXX-LARGE

I HAVE ALREADY BEEN RECRUITED TO VOLUNTEER FOR (List event or assignment)

VOLUNTEER JOB OPPORTUNITIES
Please select your top 5 choices with 1 being your first choice, 2 your second choice, etc.
9-BALL

FOOD SERVICE

SPECIAL EVENTS

AIR GUNS

HAND CYCLE

SPONSOR DINNER

ARCHERY

HOSPITATLITY/INFO SERVICES

SWIMMING

AWARDS

KID'S DAY

TABLE TENNIS

BAGGAGE HANDLERS

MEDICAL SUPPORT

TRACK

BASKETBALL

MERCHANDISE

TRANSPORTATION

BLOCK PARTY

MOTOR RALLY

TRAPSHOOTING

BOWLING

OPENING CEREMONIES

VENUE LOGISTICS

CLOSING BANQUET

POWER SOCCER

VOLUNTEER SERVICES

COMMAND CENTER

QUAD RUGBY

WAREHOUSE LOGISTICS

CROSSING GUARDS

REGISTRATION

WATER/TOWELS/ICE

CONSTRUCTION/ENGINEERING

SLALOM

WEIGHTLIFTING

ENTERTAINMENT

KAYAKING

WELCOME RECEPTION

FIELD

SOFTBALL

ASSIGN WHERE NEEDED

MEDIA CENTER

MEDIA CHECK-IN TABLES

PHOTOGRAPHY

SITE SET-UP

ADMINISTRATIVE

AVAILABLE TO ASSIST WITH PREPARATION BEFORE THE GAMES (If Yes, check box):
AVAILABLE TO LIFT:

LIGHT
SUNDAY

MEDIUM
MONDAY

YES

HEAVY (Materials/objects)
TUESDAY

WEDNESDAY

THURSDAY

FRIDAY

6:00 am - 8:00 am
8:00 am - 12:00 pm
12:00 pm - 4:00 pm
4:00 pm - 8:00 pm
8:00 pm - 10:00 pm

PLEASE SELECT WHEN YOU ARE AVAILABLE TO VOLUNTEER
Thank you in advance for your support of the
National Veterans Wheelchair Games
Please return applications to:
Susan Miller, RN
4112 Outlook Blvd. (11C-P)
Pueblo, CO 81008
Phone: (719) 553-1032
Fax: (719) 553-1102
VA FORM 0925d, APR 2010, page 2

SATURDAY