0928a National Veterans Summer Sports Clinic, Registration Che

OMB Number:
Respondent Burden: 20 minutes

NATIONAL VETERANS
SUMMER SPORTS CLINIC
REGISTRATION CHECK LIST
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.

You must completely and correctly fill out the enclosed packet, or your application will not be processed!
Registration deadline is
. A $50 late fee will be charged to any application
received after
.
Applications postmarked after

will not be accepted!

Please do not fold or staple application.
YOU MUST INCLUDE THE FOLLOWING FORMS FILLED OUT COMPLETELY. DO NOT SEND APPLICATION
WITHOUT ALL OF THE FOLLOWING:
REGISTRATION APPLICATION (Filled out by participant) (VA Form 0928b)
GENERAL MEDICAL/PHYSICAL EXAM FORM (Must be filled out completely and signed by examining clinician) (Make
sure problem list, EKG for age 40 and over, and current medications list is included in addition to the two medical pages) (VA
Form 0928c)
VA FORM 10-10 APPLICATION (Filled out by participant)
MEDIA AND NEWS RELEASE QUESTIONNAIRE (If you want publicity in your home town, fill this form out!)
(VA Form 0928d)

Please allow four weeks for your application to be processed. When accepted, you will receive
information regarding hotel and flight reservations and ground transportation.
To avoid confusion and possible loss of funds, please do not make any travel or lodging reservations
until you have received the letter notifying you that your application has been accepted.

All applications and forms must be mailed to:
Teresa Parks
National Disabled Veterans Winter Sports Clinic
VAMC (WSC)
2121 North Avenue
Grand Junction, CO 81501

VA FORM
JUN 2010

0928a

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