0926b Athlete Application, National Veterans Golden Age Games

OMB Number:
Respondent Burden: 20 minutes

ATHLETE APPLICATION
NATIONAL VETERANS GOLDEN AGE GAMES
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.
NAME (Last, First, MI)

DATE OF BIRTH

YOUR AGE AS OF

GENDER
MALE
FEMALE

ADDRESS (Street, City, State, Zip Code)

DAYTIME TELEPHONE
CELL PHONE NUMBER E-MAIL ADDRESS
NUMBER (Include area code)

DIVISION:

T-SHIRT SIZE
SMALL

AMBULATORY

VISUALLY IMPAIRED (Legally Blind)

WHEELCHAIR

XL

MEDIUM

LARGE

XXL

XXXL

TEAM COACH

TELEPHONE NUMBER OF TEAM COACH

COACH CELL PHONE NUMBER

ACCOMPANYING NON-COMPETITOR NAME

CELL PHONE NUMBER

PRIMARY VA MEDICAL CENTER

WHEELCHAIR/SCOOTER INFORMATION: Please provide the following information about your wheelchair and/or scooter. This information can
be obtained from your Prosthetics Department.)
YES

ARE YOU ABLE TO AMBULATE SHORT DISTANCES WITHOUT ASSISTANCE?
MANUFACTURER
TYPE
POWER

MODEL/MAKE

FRAME TYPE
RIGID

MANUAL

CAMBER

WEIGHT

NO
SERIAL NUMBER

OVERALL WIDTH SEAT HEIGHT

SEAT WIDTH

SEAT DEPTH

FOLDING

FRONT WHEEL/CASTER TYPE

WHEEL

CASTER HEIGHT

WIDTH

TIRE SIZE

BACK WHEEL/CASTER TYPE

WHEEL

CASTER HEIGHT

WIDTH

TIRE SIZE

WHEELCHAIR/CART INSPECTED BY

TELEPHONE NUMBER

It is your responsibility to have your wheelchair/scooter inspected by a VA prosthetic specialist and/or designee before arrival at the Games to insure
that your equipment is in good working order.
DO YOU HAVE A SERVICE DOG?

YES

NO

ASSISTIVE EQUIPMENT - All competitors are encouraged to bring their own assistive equipment (shower benches, commode chairs, etc.). A
limited number of such equipment will be available on a first-come, first-served basis during the Games. Please indicate the items needed along with
style, model numbers, etc., and we will try to accommodate you.
PLEASE INDICATE IF YOU REQUIRE MEAL ACCOMMODATION FOR A SPECIAL DIET
DIABETIC
VEGETARIAN
OTHER (Please specify)

YOU MUST PLAN TO BRING ANY MEDICATIONS YOU TAKE AND ANY ASSISTIVE EQUIPMENT YOU USE.
VA FORM
APR 2010

0926b

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SAMPLE TEMPLATE

ATHLETE NUMBER-OFFICE USE ONLY

EVENT SELECTION
NAME (Please print)

AGE (as of

GENDER
MALE

FEMALE

)

55-59

60-64

65-69

70-74

75-79

80-84

85+

Check at least two, but not more than four events. When competitors are scheduled for two events with conflicting times, attend the bracketed events
first. Otherwise, the competitor will be disqualified for failure to report for the event on time. Bracketed events are designed with an *. DO NOT
schedule conflicting events!
DIVISION CLASSIFICATION - I WILL BE COMPETING IN THE FOLLOWING DIVISION (Check only one)
AMBULATORY

VISUALLY IMPAIRED (Legally Blind)

WHEELCHAIR

WHEN YOU REGISTER IN ONE DIVISION, YOU MUST REGISTER ALL EVENTS IN THAT DIVISION
MONDAY,
GOLF - 18 HOLES

BOWLING - ALL DIVISIONS

NOTE - You may not compete in both
Golf and Checkers.
8:00 AM - 2:00 PM

*CHECKERS - ALL DIVISIONS

Starts at 8:00 AM; Ends at 4:00 PM

CYCLING - AMBULATORY ONLY

8:00 AM

55-59 & 65-69

8:00 AM

1/4 MILE

AMBULATORY

10:00 AM

80-84 & 85+

10:00 AM

1/2 MILE

AMBULATORY

WHEELCHAIR

1:00 PM

60-64 & 75-79

VISUALLY IMPAIRED

WHEELCHAIR ADAPTIVE

3:00 PM

70-74

All golfers must bring their own clubs.

(Appropriate foot attire must be worn.)

VISUALLY IMPAIRED
TUESDAY,

GOLF - 18 HOLES

BOWLING - ALL DIVISIONS

NOTE - You may not compete in both
Golf and Checkers.
8:00 AM - 2:00 PM

*CHECKERS - ALL DIVISIONS

Starts at 8:00 AM; Ends at 4:00 PM

CYCLING - AMBULATORY ONLY

8:00 AM

55-59 & 65-69

8:00 AM

1/4 MILE

AMBULATORY

10:00 AM

80-84 & 85+

10:00 AM

1/2 MILE

AMBULATORY

WHEELCHAIR

1:00 PM

60-64 & 75-79

VISUALLY IMPAIRED

WHEELCHAIR ADAPTIVE

3:00 PM

70-74

(Appropriate foot attire must be worn.)

VISUALLY IMPAIRED

All golfers must bring their own clubs.

WEDNESDAY,
*CROQUET - AMBULATORY ONLY

AMBULATORY

NOTE - You may not compete in both
Croquet and Table Tennis.
8:00 AM

60-64

9:30 AM

70-74

10:30 AM

80-84 & 85+

1:00 PM

75-79

2:00 PM

65-69

3:00 PM

55-59

*SHUFFLEBOARD
VISUALLY IMPAIRED
WHEELCHAIR

*TABLE TENNIS
AMBULATORY
WHEELCHAIR

8:00 AM

80-84 & 85+

8:00 AM

60-64

9:30 AM

65-69

9:30 AM

55-59

10:30 AM

75-79

10:30 AM

70-74

1:00 PM

55-59

1:00 PM

80-84 & 85+

2:00 PM

70-74

2:00 PM

75-79

3:00 PM

60-64

3:00 PM

65-69

THURSDAY,
DOMINOES - ALL DIVISIONS

*NINE BALL
AMBULATORY

NOTE - Competitors may not
compete in both Dominoes and
Nine Ball.

WHEELCHAIR

*HORSESHOES
AMBULATORY
WHEELCHAIR
VISUALLY IMPAIRED

**SWIMMING
AMBULATORY
1:00 PM

WHEELCHAIR

ALL AGE GROUPS

8:00 AM

75-79

8:00 AM

70-74

9:30 AM

80-84 & 85+

9:30 AM

55-59

FREESTYLE 25 YARD

55-59 & 75-79

10:30 AM

60-64

10:30 AM

65-69

FREESTYLE 50 YARD

10:00 AM

60-64 & 70-74

1:00 PM

70-74

1:00 PM

60-64

BACKSTROKE 25 YARD

1:00 PM

80-84 & 85+

2:00 PM

55-59

2:00 PM

80-84 & 85+

BACKSTROKE 50 YARD

3:00 PM

65-69

3:00 PM

65-69

3:00 PM

75-79

8:00 AM

**NOTE: You may select no more than two swimming events which will count toward two of the total of four events that you may compete
in. If you have afternoon events that conflict with Swimming, you must make a choice between those events or swimming.
FRIDAY,
SHOT PUT
AMBULATORY
WHEELCHAIR
8:00 AM - 12:00 PM
VA FORM 0926b, APR 2010, page 2

AIR RIFLE - ALL DIVISIONS
8:00 AM - 12:00 PM

DISCUS
AMBULATORY

WHEELCHAIR

8:00 AM - 12:00 PM
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