0926h Non-Competitor Application, National Veterans Golden Age

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

NON-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)

DAYTIME TELEPHONE
NUMBER (Include area code)

ADDRESS (Street, City, State, Zip Code)

E-MAIL ADDRESS

CELL PHONE NUMBER

IF REPRESENTING A VA MEDICAL CENTER, WHICH ONE?
PLEASE CHECK ONLY ONE
COACH

NATIONAL OFFICIAL

DO YOU USE AN ASSISTIVE DEVICE?
SUPPORT STAFF

FAMILY/SIGNIFICANT OTHER

MANUAL
WHEELCHAIR

POWER
WHEELCHAIR

IN CASE OF EMERGENCY, NOTIFY (Name)

TELEPHONE NUMBER

RELATIONSHIP

NEXT OF KIN

TELEPHONE NUMBER

RELATIONSHIP

SCOOTER
WALKER

FOR COACHES ONLY, DOES YOUR TEAM HAVE A NAME? (If yes, what is the name of the team)
YES

NO

PLEASE LIST YOUR TEAM MEMBERS

Release of Picture/Information: I voluntarily and without compensation authorize photograph(s), video(s), and voice recording(s) to be made of me by
or on behalf of the Department of Veterans Affairs (VA), the Veterans Canteen Service (VCS), US military publications, community media outlets,
etc., while I am attending the 28th National Veterans Golden Age Games. I authorize any or all of the above to publicize and/or display such
photographs and recordings, or to provide such photographs and recordings to others of their choosing for display, without notice or payment of any
royalty, fee, or other compensation of any character to me for the use of my picture and/or voice. I understand that the said picture(s) and/or voice
recording(s) are intended to publicize and give recognition to the National Veterans Golden Age Games. Also, I authorize storage of my registration
and event data in the electronic media.

SIGNATURE

VA FORM
FEB 2014

0926h

DATE