0929h Media and News Release Questionnair, National Veterans C

OMB Number:
Respondent Burden: 20 minutes

MEDIA AND NEWS RELEASE
QUESTIONNAIRE
NATIONAL VETERANS CREATIVE ARTS FESTIVAL
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.
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.

Artists and Performers: Please complete this form and return by

.

Please complete this form to help our Festival staff highlight your creative arts achievements. We request that you take the time to
consider and answer each questions carefully,keeping in mind that your responses here are all that the staff will have to compose your
introduction in the show (or art exhibit), your write-up in the Festival bio booklet, and your Hometown News Release (if you want one).
NAME (Last, First, MI)

DATE OF BIRTH

ADDRESS (Street, City, State, Zip Code)

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

PREFERRED NAME/NICKNAME

PLEASE CONFIRM YOUR BRANCH OF SERVICE
ARMY

AIR FORCE

COAST GUARD

MARINE CORPS

NAVY

NATIONAL GUARD

OTHER (Please specify)
IF YOU ARE A PEACETIME VETERAN, WHERE AND WHEN DID YOU SERVE?
DATES OF SERVICE? (Month/Year)

DID YOU SERVE IN COMBAT IN ANY OF THE FOLLOWING CONFLICTS?
KOREA

WWII

VIETNAM

THE GULF WAR

AFGHANISTAN

IRAQ

OTHER (Please specify)

TO

WERE YOU INJURED IN COMBAT?
YES

JOB IN SERVICE?

RANK ACHIEVED

NO

WHICH VETERANS SERVICE ORGANIZATIONS ARE YOU A MEMBER?
AMVETS

MOPH

PVA

DAV

VFW

AMERICAN LEGION

OTHER

WHAT IS YOUR PRIMARY VA MEDICAL CENTER (OR MILITARY HOSPITAL) (City, State)

HOW MANY PAST YEARS HAVE YOU PARTICIPATED IN THE
NATIONAL VETERANS CREATIVE ARTS FESTIVAL?

IN WHAT DIVISION(S) OF THE CREATIVE ARTS COMPETITION DID YOU
RECEIVE YOUR NATIONAL MEDAL(S)?
ART

CREATIVE WRITING

DANCE

DRAMA

MUSIC

A Biographical Booklet about all of this year's participants will be prepared and included with the printed Program that will be handed
out during the stage show and art exhibit. It will include a small photo and quote from each artist and performer. We hope that
everyone will allow us to include them in this very special publication.
Veterans: Please check one of the two statements below.
I DO GIVE MY PERMISSION FOR MY NAME AND ANY INFORMATION CONTAINED ON THIS FORM, TO BE INLCUDED IN A BIOGRAPHY
BOOKLET, AND POSSIBLEY INCLUDED IN THE SCRIPT OF THE NATIONAL VETERANS CREATIVE ARTS FESTIVAL STAGE SHOW.
I DO NOT GIVE MY PERMISSION FOR MY NAME AND ANY INFORMATION CONTAINED ON THIS FORM, TO BE INLCUDED IN A
BIOGRAPHY BOOKLET, AND POSSIBLEY INCLUDED IN THE SCRIPT OF THE NATIONAL VETERANS CREATIVE ARTS FESTIVAL STAGE
SHOW.

PARTICIPANT SIGNATURE
VA FORM
APR 2010

0929h

DATE
Adobe LiveCycle Designer

1. IN ONE SENTENCE OR LESS, DESCRIBE HOW PARTICIPATION IN THE CREATIVE ARTS ENHANCES YOUR LIFE AND MAKES YOU FEEL.

2. WHAT WOULD YOU TELL OTHER VETERANS ABOUT THE VALUE OF THE CREATIVE ARTS (art, creative writing, dance, drama or music) AND
WHY ARE THEY A GOOD FORM OF THERAPY?

3. WHEN AND HOW DID YOU BEGIN YOUR FORM OF THE ARTS (include formal or informal training)?

4. WHY DID YOU ENTER THE NATIONAL VETERANS CREATIVE ARTS COMPETITION?

5. HOW DID YOU CHOOSE YOUR ENTRY? DOES THIS SELECTION HAVE PARTICULAR MEANING TO YOU?

6. WHAT WOULD YOU LIKE OTHERS TO KNOW ABOUT YOUR PARTICULAR TALENT? (This could include the difficulties you've overcome to be where
you are in your art, or maybe an experience that inspired you to create art or perform.)

7. TELL US HOW IT FEELS TO BE A NATIONAL WINNER CHOSEN TO PERFORM AND/OR DISPLAY YOUR WORK. WHAT DOES THE FESTIVAL
MEAN TO YOU?

8. HOW HAVE YOUR EXPERIENCES WITH THE CREATIVE ARTS IN VA (for example at your local VA facility and/or past Creative Arts Festivals)
IMPACTED YOUR LIFE?

9. TELL US EXACTLY WHAT YOU ARE DOING IN THE SHOW. IF YOU ARE AN ARTIST, GIVE US A DETAILED DESCRIPTION OF YOUR
ARTWORK. PLEASE BE SPECIFIC.

10. ARE THERE ANY OTHER THINGS ABOUT YOU OR YOUR PERFORMANCE OR ARTWORK THAT YOU WOULD LIKE US TO KNOW? (Or
include in your news release if you want one.)

VA FORM 0929h, APR 2010, page 2

11. IF YOU HAVE ATTENDED THE FESTIVAL BEFORE, WHAT IS THE BEST FESTIVAL EXPERIENCE YOU HAVE HAD? WHAT WOULD YOU LIKE
OTHERS TO KNOW ABOUT THIS EVENT?

Dear Participant: The Public Affairs Team has the responsibility to publicize this event and the veterans attending the Festival. By
preparing an individual news release, which includes the general category of your disability, we hope to reach other veterans who may
benefit from the program. Photographs are taken of all veterans who give us permission below to prepare a Media and News Release,
which allows us to contact the news media in your area. We will provide you with a copy of that photograph. Please indicate your
decision by answering the following questions and signing the form. The information you provide us will be used by the Festival's
Public Affairs team to prepare a news release for your local news media through the Festival's web site.
DO YOU WANT US TO PREPARE A NEWS RELEASE ABOUT YOUR PARTICIPATION IN THIS EVENT?
YES

NO

IF YOU WOULD LIKE A NEWS RELEASE, PLEASE ANSWER THE FOLLOWING QUESTIONS.
1. DO WE HAVE YOUR PERMISSION TO INCLUDE YOUR PHONE NUMBER ON YOUR NEWS RELEASE? THE NEWS RELEASE WILL BE
POSTED ON THE FESTIVAL WEB SITE TO ALLOW REPORTERS TO CONTACT YOU DIRECTLY IF THEY WISH TO INTERVIEW YOU. IF YOU DO
NOT WISH TO HAVE YOUR PHONE NUMBER LISTED, WE WILL PREPARE YOUR NEWS RELEASE WITHOUT IT. (We will release the phone number
to media if they call and want to interview you.)
YES, YOU MAY INCLUDE MY PHONE NUMBER ON MY NEWS RELEASE FOR POSTING ON THE WEB SITE.
NO, PLEASE DO NOT INCLUDE MY PHONE NUMBER ON MY NEWS RELEASE FOR POSTING ON THE WEB SITE.
2. PLEASE LIST THE NAMES OF THE DAILY AND WEEKLY NEWSPAPERS CLOSEST TO YOUR HOME. INCLUDE THE FULL NAME OF THE
NEWSPAPAER. (If you do not know, please give us the name of the closest large city to where you live.)

PLEASE SIGN AND DATE BELOW.

PARTICIPANT SIGNATURE

DATE

PLEASE PHOTOCOPY THIS COMPLETED FORM FOR YOUR OWN RECORDS AND MAIL ORIGINAL TO:
NATIONAL VETERANS CREATIVE ARTS FESTIVAL (117)
VA MEDICAL CENTER
4801 VETERANS DRIVE
ST. CLOUD, MN 56303

VA FORM 0929h, APR 2010, page 3