0927f Volunteer Registration Application, National Veterans Te

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

VOLUNTEER REGISTRATION APPLICATION
NATIONAL VETERANS TEE TOURNAMENT
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.
PLEASE PRINT - IF YOU MUST CANCEL, PLEASE CONTACT US AT:

NAME (Last, First, MI)

DATE OF BIRTH

NAME TAG PREFERENCE

ADDRESS (Street, City, State, Zip Code, and County)

HOME TELEPHONE
WORK TELEPHONE
CELL TELEPHONE NUMBER
NUMBER (Include area code) NUMBER (Include area code) (Include area code)

PLEASE INDICATE YOUR T-SHIRT SIZE

E-MAIL ADDRESS

SMALL

MEDIUM

LARGE

XL

XXL

XXXL

GENDER
MALE

IF YOU ARE A VA EMPLOYEE VOLUNTEER,
PLEASE LIST YOUR VA MEDICAL FACILITY

SERVICE/DEPARTMENT

TELEPHONE NUMBER (Include area code)

SUPERVISORS SIGNATURE (VA employee volunteers need
to have authorized absence approved by their supervisor)

IN CASE OF AN EMERGENCY, CONTACT:

TELEPHONE NUMBER

FEMALE

ROUTING SYMBOL

RELATIONSHIP

VOLUNTEERS NEEDING LODGING: If you live outside the direct commuting area (25 miles), of the NVTEE Tournament Event,
and need to stay at the hotel, please indicate the nights you will need a room. All volunteers will be assigned two-to-a-room. A
Volunteer who stays at the hotel will be required to volunteer all day as assigned by the Volunteer Coordinator.
ROOM PREFERENCE

ROOM NEEDED
MONDAY

TUESDAY

WEDNESDAY

THURSDAY

ESTIMATED ARRIVAL DATE/TIME

SMOKING
A.M.

/

NON-SMOKING

P.M.

NAME OF ROOMMATE PREFERENCE
VOLUNTEER

COMPETITOR

TRANSPORTAION
WILL YOU USE YOUR OWN VEHICLE TO TRAVEL BACK AND FORTH TO THE EVENT VENUES?
MEALS (Check each meal you plan on eating with us)
DO YOU HAVE SPECIAL DIETARY NEEDS? (If yes, describe)
BREAKFAST
MONDAY
TUESDAY
WEDNESDAY
THURSDAY
FRIDAY
VA FORM
FEB 2014

0927f

LUNCH

YES

NO
DINNER

YES

NO

ACTIVITY SIGN UP
1. Check the Preference column for the day/time of each event that you would like to volunteer for.
2. If you chose more than one event on the same day/time, RANK each event by placing a 1 as your first choice or a 2 as your second
choice.
GOLF BUDDY VOLUNTEER DATES AND TIMES
RIV (RIVERSIDE); WL (WEST LIBERTY); SOL (LAKE MCBRIDE); NL ( QUAIL CREEK); ELKS (ELKS)
GOLF COURSE

DATE

HAVE YOU EVER GOLFED BEFORE?

PREFERENCE/
RANK

TIME

YES

NO

HOW MANY ROUNDS OF GOLF PER YEAR?
GOLF EXPERIENCE

IS THERE A PARTICIPANT YOU WOULD PREFER TO BE A GOLF
BUDDY FOR?
HAVE YOU EVER WORKED WITH ANYONE
WITH DISABILITIES? (If "yes", please specify)

USGA HANDICAP
INSTRUCTOR EXPERIENCE

ARE YOU INTERESTED IN HAVING ANY TRAINING
REGARDING WORKING WITH DISABILITIES?

RECREATIONAL GOLFER
FOOD (Serve and clean-up (help veterans) (act as a sighted guide))
Breakfast 0630-0800, Lunch 1030-1300, Dinner 1630-1900
MEALS
GOLF COURSE
DATE
BREAKFAST LUNCH DINNER

NURSES
LPN, Paramedic, EMT

BOWLING

KAYAKING

DAY

DATE

TIME

PREFERENCE/
RANK

TIME

PREFERENCE/
RANK

HORSEBACK RIDING
DAY

GOLF COURSE

DAY

NO

YES

NO

DATE

TIME

PREFERENCE/
RANK

DATE

TIME

PREFERENCE/
RANK

TIME

PREFERENCE/
RANK

ENTERTAINMENT (Casino Night)
DATE

REGISTRATION (Check participants in/help with luggage to room)
DAY

YES

DATE

VA FORM 0927f, FEB 2014, page 2

TIME

PREFERENCE/
RANK

DAY

DATE

TRANSPORTATION (Drive vehicles, assist with boarding/unloading veterans)
DAY

DATE

TIME

PREFERENCE/
RANK