VA0925 (SF) Veteran Registration Form

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

VETERAN NUMBER-OFFICE USE ONLY

VETERAN REGISTRATION FORM
EVENT SELECTION
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 5 minutes. This includes the time it will take to read instructions, gather the necessary facts and fill out the forms.
VETERAN INFORMATION
NAME (Last, First, MI)

SOCIAL SECURITY NO.
(Last 4 digits only)

DATE OF BIRTH
(MM/DD/YYYY)

GENDER

ADDRESS (Street, City, State, Zip Code)

DAYTIME TELEPHONE
NO. (Include area code)

CELL TELEPHONE NO.
(Include area code)

T-SHIRT SIZE

MALE

E-MAIL ADDRESS

FEMALE

S

M

L

XL

2X

3X

ARE YOU ATTENDING WITH A CAREGIVER?
YES

(If yes, Name of caregiver)

NO

MILITARY INFORMATION
BRANCH OF SERVICE
ARMY

AIR FORCE

COAST GUARD

MARINE CORPS

NAVY

OTHER (Please specify)

NATIONAL GUARD

CURRENTLY ON ACTIVE DUTY

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

KOREA

THE GULF WAR

VIETNAM

AFGHANISTAN

IRAQ

WERE YOU EVER HELD AS A POW? (If yes, where)

YES

NO

ARE YOU RATED BY VA FOR A SERVICE CONNECTED DISABILITY?

YES

NO

OTHER (Please specify)
WHAT DID YOU DO IN THE SERVICE?

VA HEALTH CARE INFORMATION
ARE YOU ENROLLED FOR VA HEALTHCARE?
YES
NO (If you checked, no, you must submit a completed 10-10EZ, Application for Health Benefits
DO YOU RECEIVE YOUR CARE AT A
VAMC

FACILITY NAME AND ADDRESS (Street, City, State, Zip Code)

WHAT IS YOUR VA STATUS?

CBOC

INPATIENT

OUTPATIENT

PRIVATE PHYSICIAN
NAME OF VA THERAPIST/STAFF CONTACT PERSON (Last, First, MI) CELL TELEPHONE NO.
(Include area code)
ARE YOU ATTENDING WITH A TEAM/COACH?

YES

NO

TEAM LEADER/COACH NAME (Last, First, MI) (If applicable)

IS THIS YOUR FIRST TIME
ATTENDING THIS EVENT?
YES

NO

OTHER MEDICAL EQUIPMENT

0925(SF)

CELL TELEPHONE NO.
(Include area code)

E-MAIL ADDRESS

CHECK OTHER VA NATIONAL EVENTS YOU HAVE ATTENDED (Check all that apply)
WHEELCHAIR GAMES

WINTER SPORTS CLINIC

TEE TOURNAMENT

GOLDEN AGE GAMES

SUMMER SPORTS CLINIC

CREATIVE ARTS FESTIVAL

WHAT MEDICAL EQUIPMENT WILL YOU BRING?
OXYGEN
NEBULIZER
CPAP

VA FORM
FEB 2014

E-MAIL ADDRESS

WALKER

WHEELCHAIR

ARE YOU BRINGING A
SERVICE DOG?
(Pets are not allowed)
YES

NO

WHEELCHAIR INFORMATION

You MUST have your wheelchair inspected by a VA prosthetics specialist before arrival at this Event. It is your responsibility to ensure that your
equipment is in good working order before you depart for the Event. Coordinate through your team coordinator or your VA prosthetics representative.
Make sure that all chairs issued by VA are listed on your prosthetic eligibility card by serial number, and bring your card.
ARE YOU ABLE TO AMBULATE SHORT DISTANCES WITHOUT ASSISTANCE?

YES

NO

WHEELCHAIR INSPECTION (You must provide the following information about ALL of your chairs)
MAKE
TYPE

MODEL
MANUAL

HEAD
(Control)

MOUTH
(Control)

MANUAL

HEAD
(Control)

MOUTH
(Control)

MAKE
TYPE

SERIAL #

HAND
DESCRIPTION
(Control)
MODEL

SERIAL #

HAND
(Control) DESCRIPTION

INSPECTED BY (Print)

SIGNATURE
EMERGENCY INFORMATION
ADDRESS (Street, City, State and Zip Code)

IN CASE OF EMERGENCY, NOTIFY (This must be filled out completely)
NAME (Last, First, MI)
TELEPHONE NUMBER

RELATIONSHIP TO VETERAN

REMARKS

PARTICIPANT AGREEMENT
This event is an extension of VA health care. Compliance with VA regulations and policies is mandatory for all participants. Bringing weapons,
unprescribed drugs or paraphernalia, unexcused non-participation, exhibiting disruptive behavior and harassment of others in any form, will not be
tolerated and may result in immediate expulsion and may affect future participation.
I acknowledge that participating in this event is a potentially hazardous activity, but represent that I am trained adequately and am medically
able. I agree to assume all risks associated with this event, including but not limited to serious bodily injury, including death, and property
damage. Participant consents to medical treatment in the case of emergency and agrees to assume full responsibility for payment of any and all fees
incurred as a result of medical treatment.
Participant agrees to assume any liability and expense incurred as a result of property damage arising from negligence or intentional misconduct of
participant or their guest.

SIGNATURE
VA FORM 0925(SF), FEB 2014, page 2

DATE (MM/DD/YYYY)