0926b Athlete Application, National Veterans Golden Age Games

OMB Number: 2900-0759
Expiration Date: Xxx, 20XX
Respondent Burden: 20 minutes

ATHLETE APPLICATION
2014 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
JANUARY 1, 2014

GENDER
MALE
FEMALE

ADDRESS (Street, City, State, Zip Code)

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

PLEASE INDICATE T-SHIRT SIZE

DIVISION:
AMBULATORY

WHEELCHAIR

VISUALLY IMPAIRED (Legally Blind)

PRIMARY VA MEDICAL CENTER

SMALL

MEDIUM

LARGE

XL

2X

3X

4X

TEAM COACH

TELEPHONE NUMBER OF TEAM COACH

COACH CELL PHONE NUMBER

IN CASE OF EMERGENCY, NOTIFY (Name)

PHONE NUMBER

RELATIONSHIP

NEXT OF KIN

PHONE NUMBER

RELATIONSHIP

WHEELCHAIR/SCOOTER INFORMATION: Please provide the following information about your wheelchair and/or scooter. This information can
be obtained from your Prosthetics Department.
ARE YOU ABLE TO AMBULATE SHORT DISTANCES WITHOUT ASSISTANCE?
MANUFACTURER
TYPE

YES

MODEL/MAKE

FRAME TYPE

CAMBER

WEIGHT

NO
SERIAL NUMBER

OVERALL WIDTH SEAT HEIGHT

SEAT WIDTH

SEAT DEPTH

POWER
MANUAL

RIGID

SCOOTER

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 the athlete's responsibility to have 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.
SERVICE DOG WILL ACCOMPANY ATHLETE?

YES

NO

ASSISTIVE EQUIPMENT - All Athletes must bring their own assistive/durable medical equipment (shower benches, commode chairs,etc.) for use
during the Games.
YOU MUST BRING ALL MEDICATIONS TAKEN AND ANY ASSISTIVE EQUIPMENT USED.

VA FORM
FEB 2014

0926b

ATHLETE NUMBER-OFFICE USE ONLY

ATHLETE EVENT SELECTION
ATHLETE'S NAME (Please print)

AGE (as of January 1, 2014)

GENDER
MALE

FEMALE

55-59

60-64

65-69

70-74

75-79

80-84

85+

DIVISION CLASSIFICATION - I WILL BE COMPETING IN THE FOLLOWING DIVISION (Check only one)
AMBULATORY

VISUALLY IMPAIRED (Legally Blind)
(Bowling, Horseshoes, Shuffleboard)

WHEELCHAIR
(Bowling, Horseshoes, Nine Ball, Table Tennis, Shuffleboard)

YOU WILL COMPETE IN THIS DIVISION FOR ALL OF YOUR REGISTERED EVENTS
Check at least two, but not more than four events. Tournament events are designated with an *. DO NOT schedule conflicting events!
**The following sports count as one event Field, Swimming and Track.
Exhibition events do not count towards or against your minimum two and maximum four events.
SUNDAY, JUNE 29, 2014
*DOMINOES
ALL ATHLETES
ONE DIVISION

*CHECKERS
ALL ATHLETES
ONE DIVISION

*TABLE TENNIS
WHEELCHAIR

AMBULATORY

1:00 p.m. 70-74 & 60-64

1:00 p.m. 80-84 & 85+

1:00 p.m.

Wheelchair - All Ages

3:00 p.m.

2:00 p.m.

3:00 p.m.

80-84 & 85+

55-59

75-79

5:00 p.m. 85+ & 80-84

3:00 p.m. 70-74 & 65-69

4:00 p.m.

75-79 & 70-74

6:00 p.m. 75-79

5:00 p.m. 55-59

6:00 p.m.

60-64 & 65-69

7:00 p.m.

55-59

MONDAY, JUNE 30, 2014
BOWLING
AMBULATORY
WHEELCHAIR

*HORSESHOES
(Ambulatory Division Only)

SWIMMING
(Ambulatory Division Only)

VISUALLY IMPAIRED
8:00 a.m.

80-84 & 85+

9:00 a.m.

9:00 a.m.

70-74 & 75-79

11:00 a.m.

NOTE: **Counts as one
event (maximum of three
swimming events)
Visually Impaired - All Ages 8:00 a.m. - Noon

1:00 p.m.

65-69

1:00 p.m.

75-79, 80-84 & 85+

FREESTYLE 25 YARD

2:00 p.m.

60-64

3:00 p.m.

65-69 & 70-74

FREESTYLE 50 YARD

3:00 p.m.

55-59

5:00 p.m.

60-64

BACKSTROKE 25 YARD

7:00 p.m.

55-59

BADMINTON
(Demonstration Sport)
(Ambulatory Division Only)
1:00 p.m.

Wheelchair - All Ages

*NINEBALL
(Ambulatory
Division Only)

All Ages

5:00 p.m. 65-69

*DOMINOES
ALL ATHLETES
ONE DIVISION
5:00 p.m.

*CHECKERS
ALL ATHLETES
ONE DIVISION

60-64

5:00 p.m. 65-69

BACKSTROKE 50 YARD
TUESDAY, JULY 1, 2014

GOLF
(Ambulatory Division Only)

FIELD
(Ambulatory Division Only - All Ages)

NOTE: **Counts as one event
8:00 a.m.

JAVELIN

9:30 a.m.

SHOT PUT

8:00 a.m. - 1:00 p.m. All Ages

11:00 a.m. DISCUS
TRACK
(Ambulatory Division Only)
(All Ages)

*SHUFFLEBOARD
(Ambulatory Division Only)

NOTE: **Counts as one event
1:00 p.m. - 4:00 p.m.
Appropriate foot attire must be worn
1:00 p.m.

1/2 MILE POWER WALK

1:00 p.m.

1 MILE POWER WALK

1:00 p.m.

1 MILE PRECISION WALK

1:00 p.m.

80-84 & 85+

2:00 p.m.

70-74 & 75-79

3:00 p.m.

60-64 & 65-69

6:00 p.m.

55-59

*NINEBALL

AIR RIFLE
(Ambulatory Division Only)

WHEELCHAIR

AMBULATORY

8:00 a.m.

80-84 & 85+

8:00 a.m.

Wheelchair - All Ages

9:00 a.m.

75-79

9:00 a.m.

80-84 & 85+

10:00 a.m. 70-74

10:00 a.m.

75-79

1:00 p.m.

65-69

11:00 a.m.

70-74

2:00 p.m.

60-64

1:00 p.m.

60-64

3:00 p.m.

55-59

2:00 p.m.

55-59

WEDNESDAY, JULY 2, 2014
CYCLING
(Ambulatory Division Only)

8:00 a.m. - 1:00 p.m.
Appropriate footwear must be worn.
1/4 MILE COURSE
1/2 MILE COURSE
VA FORM 0926b, FEB 2014, page 2

*HORSESHOES
VISUALLY IMPAIRED

*SHUFFLEBOARD
WHEELCHAIR

VISUALLY IMPAIRED

8:00 a.m.

Visually Impaired - All Ages

8:00 a.m.

10:00 a.m.

Wheelchair - All Ages

10:00 a.m.

WHEELCHAIR

Wheelchair - All Ages
Visually Impaired - All Ages

FLY CASTING &
FLY TYING
(Exhibition Event)
8:00 a.m.

All Athletes