Fillable Printable VA Form 0927b
Fillable Printable 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 BIRTH GENDER
MALE FEMALE
ADDRESS (Street, City, State, Zip Code,
and County)
DAYTIME TELEPHONE
NUMBER (Include area code)
EVENING TELEPHONE
NUMBER (Include area code)
NAME TAG PREFERENCE E-MAIL ADDRESS PRIMARY VA MEDICAL CENTER
(City & State)
PLEASE INDICATE YOUR T-SHIRT SIZE
SMALL MEDIUM LARGE XL XXL XXXL OTHER
WHAT BRANCH OF SERVICE WERE YOU IN?
AIR FORCE ARMY MARINE CORPS NAVY COAST GUARD OTHER
WILL YOU BE ACCOMPANIED BY A TRAINED/CERTIFIED ASSISTANCE DOG?
YES NO
WILL YOU REQUIRE A DOG SITTER?
YES NO
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 TIME TRAVEL MODE (Select one)
OWN VEHICLE AIR BUS VANPOOL
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 HANDED LEFT HANDED
HAVE YOU EVER GOLFED BEFORE?
YES NO
(If "No", skip the next two questions
ARE YOU BRINGING YOUR OWN GOLF CLUBS?
YES NO
VA FORM
JAN 2013
0927b
DO YOU NEED A SPECIALIZED GOLF CART TO PLAY?
YES NO
IF "YES"
SINGLE RIDER PARA RIDER
YOUR AVERAGE GOLF SCORE FOR NINE HOLES
HANDICAP
IF YOU DO NOT PLAY AN ENTIRE ROUND ON EACH HOLE, DO YOU GENERALLY SHOOT
PAR BOGEY DOUBLE BOGEY TRIPLE BOGEY HIGHER
ARE YOU BRINGING A GOLF BUDDY
YES NO
(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)
GOLFING KAYAKING BOWLING HORSEBACK RIDING
ROOMMATE PREFERENCE (Select one)
PAID COMPANION
VETERAN PARTICIPANT
FAMILY VOLUNTEER
NAME RELATIONSHIP
ROOM ARRANGEMENTS
IS A (HANDICAP) ACCESSIBLE ROOM MEDICALLY REQUIRED? (If yes, why?)
YES NO
ARE SEPARATE BEDS REQUIRED?
YES NO
ARE YOU A SMOKER?
YES NO
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
