Form VA Form 10-7055 VA Form 10-7055 Application for Voluntary Service

OMB Number 2900-0090
Estimated Average: 15 min.
EXP: XX/XX/XXXX

APPLICATION FOR VOLUNTARY SERVICE
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 15 minutes. This includes the time it will take to read
instructions, gather the necessary facts and fill out the form. 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.
PRIVACY ACT INFORMATION: 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.
ADDRESS (Street, City, State and Zip Code)

NAME (Last, First, Middle Initial)

Telephone Number

DATE

Date of Birth

Email Address (Optional)

ORGANIZATION MEMBERSHIP(S) Unit, Post, Chapter, if affiliated)

SEX

ASSIGNMENT PREFERENCES
1.

2.

M

F

3.

EXPERIENCE AND TRAINING (special skills/abilities)

RESTRICTIONS, LIMITATIONS OF SERVICE (Health concerns, medications, allergies, etc.)

AVAILABILITY (Days and times)

IN CASE OF EMERGENCY PLEASE CONTACT (name, relationship, phone number)

Monetary Waiver: 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 VA 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 canceled by either party upon written notice.) I hereby accept the volunteer appointment(s) as outlined above.

Volunteer's Signature

Date

I hereby appoint this applicant as a VA without-compensation employee subject to the provisions on this application. The above individual has been provided basic and
assignment specific orientations which have been documented in the official volunteer folder located in the VA Voluntary Service Office.
___________________________________________________
VAVS Program Manager - Appointing Official Signature

________________
Date

OFFICE USE ONLY
1. SUPERVISOR

2. SUPERVISOR PHONE NUMBER

3. ORIENTATIONS

4. UNIFORM

COMMENTS

VA FORM
MAR 2008

10-7055

NAME AND TITLE OF REVIEWER

EXISTING STOCK OF VA FORM 10-7055, AUG 2006, WILL BE USED.

DATE

NOTE TO STUDENTS AND PARENTS: The VA medical center is a federal building, and as such,
must be open to the public. Our employees, patients and volunteers come from diverse backgrounds.
Eligible veterans are entitled to services offered by VA, even if they have had problematic incidents in
their past - unless the law specifically disqualifies them. Our job is to provide veterans care and to
protect our employees, patients and volunteers as that care is provided.
STUDENT VOLUNTEER: If accepted, I agree to adhere to the policies and procedures of this VA
healthcare facility and to respect the confidentiality of information pertaining to the patients and their
treatment. If a patient, staff member, volunteer, and/or visitor is abusive, makes inappropriate gestures,
advances or conversation, that is in a manner which makes me feel uncomfortable, I will immediately
inform my supervisor or a VAVS staff member.
Signature____________________________________________
Date _________________
PARENT (18 AND UNDER/UNMARRIED): The above named student has my consent as parent/
guardian to serve as a Student Volunteer in this VA healthcare system. I have read the above
agreement as signed by my child/student and understand their obligation to the program if they are
accepted into the VAVS Student Volunteer Program. I also grant permission for my child/student to
receive emergency medical treatment if injured while volunteering.
Signature____________________________________________
Date __________________
NOTE: Completion of this application does not guarantee acceptance into this program.