0926j Volunteer Application, National Veterans Golden Age Game

OMB Number: 2900-0759
Expiration Date: Xxx, 20XX
Respondent Burden: 5 Minutes

VOLUNTEER APPLICATION
2014 NATIONAL VETERANS GOLDEN AGE GAMES

PRIVACY ACT: The information requested on this form is solicited under the authority of 38 U.S.C.513 and will be used in the
selection and placement of potential volunteers in the VA Voluntary Service Program. The information you supply may be disclosed
outside VA as permitted by law; possible disclosures include those described in the 'routine uses' identified in the VA system of records
57VA125 Voluntary Service Records-VA, published in the Federal Register in accordance with the Privacy Act of 1974. The routine
uses include disclosures: in response to court subpoenas, to report apparent law violations to other Federal, State or local agencies
charged with law enforcement responsibilities, to service organizations, employers and Unemployment Compensation Offices to
confirm volunteer service, and to congressional offices at the request of the volunteer. Disclosure of the information is voluntary,
however, failure to furnish the information will hamper our ability to arrange the most satisfactory assignment for you and the
Department of Veterans Affairs.
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 form will average 5 minutes. This includes the time it will take to read instructions,
gather the necessary facts and fill out the forms. The form is used to assist personnel of both voluntary organizations, which recruit
volunteers from their membership, and the VA in the selection, screening and placement of volunteers in the nationwide VA Voluntary
Service program. The volunteer program supplements the medical care and treatment of veteran patients in all VA facilities.
DATE ENTERED VSS

ORIENTATION PACKAGE MAILED

NAME (Last, First, MI)

DATE OF BIRTH

ADDRESS (Street, City, State, Zip Code)

E-MAIL ADDRESS (Home & Work)

GENDER
MALE

DAYTIME TELEPHONE NUMBER
(Include area code)

CELL PHONE NUMBER
(Include area code)

IN CASE OF EMERGENCY, NOTIFY

WORK TELEPHONE NUMBER
(Include area code)

TELEPHONE NUMBER

ORGANIZATION MEMBERSHIP IF APPLICABLE (i.e. DAV, VFW, etc.)

FEMALE

T-SHIRT SIZE
S

M

L

XL

2XL

3XL

RELATIONSHIP
ORGANIZATION CODE (To be completed by VAVS)

DO YOU HAVE ANY PHYSICAL RESTRICTIONS OR LIMITATIONS THAT WOULD RESTRICT YOUR VOLUNTEER ACTIVITIES? (If yes, please explain)
YES

NO

PLEASE INDICATE YOUR PREFERENCE FOR VOLUNTEER ASSIGNMENT(S) BELOW:
DATES

DATES
PARTICIPANT REGISTRATION

6/28/2014 - 6/29/2014

MEDICAL TRANSPORTATION

6/28/2014 - 7/3/2014

VOLUNTEER REGISTRATION

6/28/2014 - 7/2/2014

MEDICAL SUPPORT

6/28/2014 - 7/3/2014

TRANSPORTATION

6/28/2014 - 7/2/2014

CLINICAL

6/28/2014 - 7/2/2014

SITE SET-UP

6/28/2014 - 7/2/2014

CLERICAL

6/28/2014 - 7/2/2014

WHEELCHAIR REPAIR

6/28/2014 - 7/2/2014

ESCORTS

6/28/2014 - 7/2/2014

MEMORABILIA

6/28/2014 - 7/2/2014

PROSTHETICS

6/28/2014 - 7/2/2014

CUSTOMER SERVICE

6/28/2014 - 7/2/2014

WALL OF FAME

6/28/2014 - 7/2/2014

VA FORM
FEB 2014

0926j

EVENTS (You cannot choose more
than one event per day)

DATES

DATES

SHOT PUT (UNIV. OF ARKANSAS)

7/1/2014

CHECKERS (UNIV. OF ARKANSAS)

6/29/2014 - 6/30/2014

AIR RIFLE (UNIV. OF ARKANSAS)

7/1/2014

DISCUS THROW (UNIV. OF AR)

7/1/2014

SWIMMING (UNIV. OF ARKANSAS)

6/30/2014

JAVELIN (UNIV. OF ARKANSAS)

7/1/2014

NINE BALL (UNIV. OF ARKANSAS)

6/30/2014 & 7/1/2014

SHUFFLEBOARD (UNIV. OF AR)

7/1/2014 - 7/2/2014

HORSESHOES (WALKER PARK)

6/30/2014 & 7/2/2014

EXHIBITION SPORT-BADMINTON

6/30/2014

FLY TYING - FLY CASTING

7/2/2014

BOWLING (LOWELL, AR)

6/30/2014

CYCLING (SPRINGDALE, AR)

7/2/2014

GOLF (BELLA VISTA, AR)

7/1/2014

TABLE TENNIS (UNIV. OF AR)

6/29/2014

TRACK (UNIV. OF ARKANSAS)

7/1/2014

HOSPITALITY

DATES

AIRPORT

6/28/2014 & 7/3/2014

MEALS

6/28/2014 - 7/2/2014

DIRECTIONAL GREETER

6/28/2014 - 7/2/2014

DORM HOSPITALITY

6/28/2014 - 7/2/2014

AIRPORT GREETER

6/28/2014 - 7/3/2014

BAGGAGE HANDLER

6/28/2014 - 7/3/2014

HEADQUARTERS

DATES

DOMINOES (UNIV. OF ARKANSAS)

ENTERTAINMENT
VCS BINGO

MEDIA CENTER

6/29/2014 - 6/30/2014

DATES
7/1/2014

DATES

COMMAND CENTER

6/28/2014 - 7/3/2014

MEDIA SUPPORT

6/28/2014 - 7/2/2014

COMMUNICATIONS/INFORMATION

6/28/2014 - 7/3/2014

NEWSLETTER

6/28/2014 - 7/2/2014

DATA MANAGEMENT

6/28/2014 - 7/2/2014

MEDIA PHOTOGRAPHY

6/28/2014 - 7/2/2014

CEREMONIES

DATES

AWARDS (All week)

DATES

OPENING

6/29/2014

MEDAL CEREMONY 1

6/30/2014

CLOSING

7/2/2014

MEDAL CEREMONY 2

7/1/2014

SPONSOR'S RECEPTION

6/28/2014

MEDAL CEREMONY 3

7/2/2014

VA FORM 0926j, FEB 2014, page 2

I understand and agree to abide by the following factors which have been discussed with me: volunteer rights and responsibilities,
reporting hours, fire/safety rules and regulations, reporting of special incidents, infection control, blood borne pathogens, hazard
communication, equipment and utility management, and confidentiality.
I hereby waive all claims to monetary benefits for services rendered as a volunteer worker on a "without compensation basis" for an
indefinite period. I understand that this waiver applies only to remuneration (compensation) for specific services rendered in the
Voluntary Service (VAVS) Program and is not related to any other VA services or benefits to which I may be entitled. (NOTE: VA has
entered into this agreement by the authority of 38 U.S.C., Section 513. This agreement may be cancelled by either party upon written
notice.)
I voluntarily and without compensation authorize pictures and/or voice recording to be made of me by or on my behalf of VA, VCS, US
military publications, and other magazines, veterans' publications, newspapers, and broadcast media, etc. while I am a volunteer in the
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 pictures
and/or voice recordings are intended to publicize and give recognition to the National Veterans Golden Age Games.

SIGNATURE OF VOLUNTEER

DATE

PLEASE SUBMIT COMPLETED APPLICATION TO:
Carol Kick, 2014 LOC Coordinator (135)
VA Health Care System of the Ozarks
1100 N College Avenue
Fayetteville, AR 72703
For Volunteer Committee Only:

SIGNATURE OF NVGAG CHAIR OR VOLUNTEERS/DESIGNEE

VA FORM 0926j, FEB 2014, page 3

DATE