0924b Registration Application, National Disabled Veterans Win

OMB Number:
Respondent Burden: 20 minutes

REGISTRATION APPLICATION
NATIONAL DISABLED VETERANS WINTER SPORTS CLINIC
DEADLINE:

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.
SOCIAL SECURITY NO. DATE OF BIRTH
(Last 4 digits only)

NAME (Last, First, MI)

MALE
FEMALE

ADDRESS (Street, City, State, Zip Code)

DAYTIME TELEPHONE
EVENING TELEPHONE
NUMBER (Include area code) NUMBER

DO YOU RECEIVE YOUR CARE AT A PLEASE PRINT THE NAME OF THE FACILITY YOU
RECEIVE CARE AT
VAMC OR A
CBOC
WHAT BRANCH OF SERVICE WERE YOU IN? YEARS IN SERVICE

E-MAIL ADDRESS

DO YOU GET YOUR PHYSICAL DONE AT THE
VAMC OR A

PRIVATE PHYSICIAN

WHAT SERVICE ORGANIZATIONS DO YOU BELONG TO?

ARE YOU ATTENDING WITH A TEAM? (If yes, who is your coach)

YES

NO

HAVE YOU COMPETED IN AN ORGANIZED DISABLED SPORTS EVENT?

YES

NO

HAVE YOU EVER PARTICIPATED IN THE WINTER SPORTS CLINIC?

YES

NO

IF YOU HAVE PARTICIPATED IN THE WINTER SPORTS CLINIC, PLEASE SPECIFY WHICH YEARS
WHAT IS YOUR VA STATUS?

INPATIENT

SERVICE CONNECTED?

YES

OUTPATIENT
NO

The National Disabled Veterans Winter Sports Clinic is a VA/DAV cosponsored event. The clinic is an outreach of the Grand Junction VA Medical
Center and VISN 19. Compliance with VA regulations and policies is mandatory at this event for all participants. Bringing weapons, unprescribed
drugs or paraphernalia, unexcused non-participation, exhibiting disruptive or abusive behavior and harassment of others in any form, will not be
tolerated and may result in immediate expulsion from this event and will effect future participation.
The Department of Veterans Affairs and the Disabled American Veterans encourage a safe environment for all attendees. These rules exist for the
safety of everyone involved in the clinic.
ATHLETE SIGNATURE

IN CASE OF EMERGENCY, NOTIFY (This must be filled out completely)
NAME

TELEPHONE NUMBER

ADDRESS (Street, City, State and Zip Code)

RELATIONSHIP TO PATIENT

NOTE: Registration Deadline is
. There will be a $50 late fee for any applications postmarked
.
Applications postmarked after
, will not be accepted. Applications which are not completely and correctly filled out will be
returned to you. They must be corrected or completed and resubmitted by the
deadline. Only applications received by mail
will be accepted. Please do not fold or staple the application.
For any questions regarding this application, please call Teresa Parks at (970) 263-5040.

VA FORM
APR 2010

0924b

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