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Fillable Printable VA Form 0927b

Fillable Printable VA Form 0927b

VA Form 0927b

VA Form 0927b

OMB Number: 2900-0759
Respondent Burden: 20 minutes
PARTICIPANT REGISTRATION APPLICATION
NATIONAL VETERANS TEE TOURNAMENT
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.
NAME (Last, First, MI)SOCIAL SECURITY
NO. (Last 4 digits only)
DATE OF BIRTHGENDER
MALEFEMALE
ADDRESS (Street, City, State, Zip Code,
and County)
DAYTIME TELEPHONE
NUMBER (Include area code)
EVENING TELEPHONE
NUMBER (Include area code)
NAME TAG PREFERENCEE-MAIL ADDRESSPRIMARY VA MEDICAL CENTER
(City & State)
PLEASE INDICATE YOUR T-SHIRT SIZE
SMALLMEDIUMLARGEXLXXLXXXLOTHER
WHAT BRANCH OF SERVICE WERE YOU IN?
AIR FORCEARMYMARINE CORPSNAVYCOAST GUARDOTHER
WILL YOU BE ACCOMPANIED BY A TRAINED/CERTIFIED ASSISTANCE DOG?
YESNO
WILL YOU REQUIRE A DOG SITTER?
YESNO
INDICATE ANY NEED FOR SPECIAL TRAVEL ASSISTANCE UPON ARRIVAL OR DEPARTURE. ALL PARTICIPANTS
ARE ENCOURAGED TO BRING THEIR OWN ASSISTIVE EQUIPMENT. ALL PARTICIPANTS MUST BRING THEIR
OWN MEDICATIONS.
ARRIVAL DATE AND ESTIMATED ARRIVAL TIMETRAVEL MODE (Select one)
OWN VEHICLEAIRBUSVANPOOL
IF YOU ARE NOT PLANNING TO STAY AT THE EVENT HOTEL(S), INDICATED WHERE YOU WILL BE STAYING.
(Include: Name, Street, City, State, Zip Code, and Phone Number)
IN ORDER TO HELP US ASSIGN YOU TO THE OPTIMAL GOLF GROUP AND PROVIDE ADEQUATE INSTRUCTION
FOR YOUR GOLF NEEDS, PLEASE LET US KNOW THE FOLLOWING
DO YOU GOLF?
RIGHT HANDEDLEFT HANDED
HAVE YOU EVER GOLFED BEFORE?
YESNO
(If "No", skip the next two questions
ARE YOU BRINGING YOUR OWN GOLF CLUBS?
YESNO
VA FORM
JAN 2013
0927b
DO YOU NEED A SPECIALIZED GOLF CART TO PLAY?
YESNO
IF "YES"
SINGLE RIDERPARA RIDER
YOUR AVERAGE GOLF SCORE FOR NINE HOLES
HANDICAP
IF YOU DO NOT PLAY AN ENTIRE ROUND ON EACH HOLE, DO YOU GENERALLY SHOOT
PARBOGEYDOUBLE BOGEYTRIPLE BOGEYHIGHER
ARE YOU BRINGING A GOLF BUDDY
YESNO
(If "Yes", Name:
All golf buddies must fill out a volunteer form. A volunteer form is attached to this application. If additional forms are needed
contact Sarah Steen, Volunteer Coordinator, at 319-338-0581, ext. 3607; or e-mail to: .
NAME OF GOLF BUDDY PREFERENCE, IF THERE IS A VOLUNTEER YOU PREFER
WEDNESDAY ACTIVITIES INCLUDE GOLF INSTRUCTION FOR 1/2 OF THE DAY AND THE OTHER 1/2 OF THE DAY
YOU WILL HAVE A CHOICE OF THE FOLLOWING ACTIVITIES (Rank them 1 - 4)
GOLFINGKAYAKINGBOWLINGHORSEBACK RIDING
ROOMMATE PREFERENCE (Select one)
PAID COMPANION
VETERAN PARTICIPANT
FAMILY VOLUNTEER
NAMERELATIONSHIP
ROOM ARRANGEMENTS
IS A (HANDICAP) ACCESSIBLE ROOM MEDICALLY REQUIRED? (If yes, why?)
YESNO
ARE SEPARATE BEDS REQUIRED?
YESNO
ARE YOU A SMOKER?
YESNO
PLEASE LIST ANY DIETARY RESTRICTIONS YOU HAVE
ANY OTHER PERTINENT INFORMATION?
Early arrival or late departure room rates will be at the participants or volunteers own expense. Please let us know if you
intend to come early or depart late and require additional room nights. List here the nights or call Lori Montag at
319-358-5962.
(A PAID COMPANION NEEDS TO FILL OUT A COMPANION REGISTRATION FORM.)
VA FORM 0927b, JAN 2013, page 2
sarah.steen@va.gov
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