0929b Participant Registration Application, National Veterans

OMB Number:
Respondent Burden: 20 minutes

PARTICIPANT REGISTRATION APPLICATION
NATIONAL VETERANS CREATIVE ARTS FESTIVAL
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.
NAME (Last, First, MI)

NICKNAME

SOCIAL SECURITY NO.
(Last 4 digits only)

DATE OF BIRTH

ADDRESS (Street, City, State, Zip Code)

GENDER

TELEPHONE NUMBER 1
(Include area code)

TELEPHONE NUMBER 2
(Include area code)

MALE
FEMALE
FESTIVAL ROLE (If you are a non-veteran partner selected to perform in an act with a veteran in
the stage show, please fill out a Family/Friends Registration Form)

E-MAIL ADDRESS

VETERAN STAGE SHOW PARTICIPANT (Individual Act and Chorus Member performers)
VETERAN VISUAL ARTS PARTICIPANT (Artists)
STAFF CONTACT TELEPHONE VA FACILITY NAME AND ADDRESS (Street, City, State, Zip Code)
NUMBER (Include area code)

NAME OF VA STAFF CONTACT PERSON
RESPONSIBLE FOR YOUR CREATIVE ARTS
ACTIVITIES

IS THIS YOUR FIRST TIME ATTENDING THE FESTIVAL?

WHAT IS YOUR VA STATUS?

NO

YES

INPATIENT

SERVICE CONNECTED?

OUTPATIENT

YES

NO

WHAT MEDICAL EQUIPMENT WILL YOU BRING?
OXYGEN

NEBULIZER

CPAP

WALKER

WHEELCHAIR

ELECTRIC SCOOTER

OTHER MEDICAL EQUIPMENT
WHAT BRANCH OF SERVICE WERE YOU IN? WHICH YEARS?

SHIRT SIZE (Select one)
S

TO
DO YOU HAVE ANY SPECIFIC DIETARY NEEDS? (Check all that apply)
DIABETIC

REGULAR DIET

LACTOSE FREE

CARDIAC

SOFT

VEGETARIAN

M

TALL SIZES

L

XL

2X

LT

XLT

2XT

3X

4X

5X

WHEN PLATED (Not buffet) MEALS ARE SERVED,
MY PREFERENCE IS

VEGETARIAN

MEAT

OTHER
IN CASE OF EMERGENCY, NOTIFY (This must be filled out completely)
NAME

TELEPHONE NUMBER

VA FORM
APR 2010

0929b

ADDRESS (Street, City, State and Zip Code)

RELATIONSHIP TO PARTICIPANT

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LODGING IS FREE FOR VETERANS INVITED TO PARTICIPATE AT THE NATIONAL VETERANS
CREATIVE ARTS FESTIVAL, BUT EACH PARTICIPANT WILL BE ASSIGNED A ROOMMATE.
I HAVE A ROOMMATE PREFERENCE (Indicate name of roommate)
PLEASE ASSIGN ME A ROOMMATE (Roommates will be carefully selected)
IF YOU WOULD LIKE YOUR OWN ROOM, YOU WILL BE RESPONSIBLE FOR PAYING HALF OF THE ROOM COST OF A SINGLE OCCUPANCY
ROOM, WHICH IS
PER NIGHT.
I WOULD LIKE TO HAVE MY OWN ROOM AND PAY

PER NIGHT.

IF YOU WILL BE SHARING A ROOM WITH A GUEST, YOU WILL BE RESPONSIBLE FOR PAYING HALF OF THE ROOM COST ON ANY NIGHTS
THE GUEST IS NOT STAYING WITH YOU,
(single rate). YOUR GUEST WILL BE RESPONSIBLE FOR PAYING
(the rate for one additional guest) ON THE NIGHTS THEY STAY WITH YOU.
I WOULD LIKE A ROOM TO SHARE WITH MY GUEST, I WILL PAY
PER NIGHT ON ANY NIGHTS I DON'T HAVE A
PAYING GUEST. MY GUEST WILL STAY WITH ME THE FOLLOWING NIGHTS AND WILL PAY HALF OF THE ROOM COST
(
double rate).

ROOM REQUIREMENTS
I WILL NEED A HANDICAPPED ACCESSIBLE ROOM
OTHER ROOM NEEDS
IMPORTANT - PAYMENT FOR ROOMS MUST ACCOMPANY THIS FORM. PAYMENT MUST BE MADE BY

IN THE

FORM OF A CHECK OR MONEY ORDER PAYABLE TO THE DEPARTMENT OF VETERANS AFFAIRS,
I UNDERSTAND THAT I MUST PRESENT A CREDIT CARD UPON CHECK-IN TO PAY FOR INCIDENTALS (room service, in-room movies, telephone
calls, internet service) THAT I MIGHT INCUR DURING THE WEEK. I ALSO UNDERSTAND THAT I WILL BE RESPONSIBLE FOR PAYMENT OF ANY
FINE(S) INCURRED.
SUBMIT COMPLETED PARTICIPANT REGISTRATION FORM NO LATER THAN

VA FORM 0929b, APR 2010, page 2

TO:

OMB Number:
Respondent Burden: 20 minutes

TRAVEL INFORMATION
NATIONAL VETERANS CREATIVE ARTS FESTIVAL
EVENT DEADLINE:
*Note to Festival participants, staff and others: VA staff will be providing complimentary ground transportation from and to the
Airport on both the main arrival and departure days.
PARTICIPANT NAME (Last, First, MI)

TELEPHONE NUMBER 1
(Include area code)

VA FACILITY NAME

VA FACILITY ADDRESS (Street, City, State and Zip Code)

TELEPHONE NUMBER 2
(Include area code)

VA FACILITY TELEPHONE NUMBER (Include area code)

MODE OF TRANSPORTATION
AIR

CAR

BUS

I NEED ASSISTANCE GETTING ON AND OFF THE AIRCRAFT
TRAIN BECAUSE I:

AM VISUALLY IMPAIRED

YES

USE A WHEELCHAIR

NO
OTHER

ARRIVAL INFORMATION
DATE OF ARRIVAL

TIME

NUMBER OF PEOPLE TRAVELING TOGETHER

IS A STAFF PERSON ACCOMPANYING PARTICIPANT
(If Yes, name of staff person)

YES

NO

NAME OF AIRPORT, BUS OR TRAIN STATION AND CITY AND STATE ARRIVING INTO
FLIGHT/BUS/TRAIN NUMBER

FROM

AIRLINE

DEPARTURE INFORMATION
DEPARTING VIA
CAR
DATE OF DEPARTURE

TIME

FLIGHT/BUS/TRAIN NUMBER

BUS

TRAIN

AIRLINE

SUBMIT COMPLETED FORM NO LATER THAN

TO:

LINDA ZAIONTZ, HOST SITE COORDINATOR (11K)
NATIONAL VETERANS CREATIVE ARTS FESTIVAL
SOUTH TEXAS VETERANS HEALTH CARE SYSTEM
7400 MERTON MINTER BLVD
SAN ANTONIO, TX 78229
PHONE: (210) 617-5125
FAX: (210) 617-5276
linda.zaiontz@va.gov

VA FORM 0929b, APR 2010, page 3

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