Va Form 0928f - Media Staff Application
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1OMB Number: 2900-0759
Respondent Burden: 5 Minutes
MEDIA STAFF APPLICATION
NATIONAL VETERANS SUMMER SPORTS CLINIC
SAN DIEGO, CALIFORNIA
PRIVACY ACT: 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.
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 form will
average 5 minutes. This includes the time it will take to read instructions, gather the necessary facts and fill out the forms. 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.
This application must be FULLY completed. (Please type or Print)
NAME (Last, First, Middle Initial)
ADDRESS (City, State and Zip Code)
CURRENT JOB TITLE
DATE OF BIRTH
DAYTIME PHONE NUMBER
EVENING PHONE NUMBER
E-MAIL ADDRESS
PREVIOUS VOLUNTEER
(Include area code)
(Include area code)
(If yes, how many years
NO
YES
SHIRT SIZE (Check one)
ARE YOU A VETERAN OF
IF THIS IS YOUR FIRST YEAR, WHO REFERRED
DEPARTMENT OF VETERANS
THE ARMED FORCES
YOU TO THE SUMMER SPORTS CLINIC
AFFAIRS EMPLOYEE
SMALL
MEDIUM
LARGE
X-LARGE
XX-LARGE
NO
YES
NO
YES
NAME OF FACILITY
FACILITY DIRECTOR'S NAME
FACILITY ADDRESS (City, State and Zip Code)
I support the above named individuals application to participate in the
National Veterans Summer
Sports Clinic. (Government Employees ONLY)
IMMEDIATE SUPERVISOR'S SIGNATURE
DIRECTOR'S NAME
APPROVED
APPROVED
DISAPPROVED
DISAPPROVED
JOB TITLE/ROLE AT THE CLINIC (Check one)
LICENSE AND/OR CERTIFICATION THAT APPLIES TO
CLINIC POSITION
HOMETOWN NEWS
PHOTOGRAPHER
OTHER
(Please specify)
MEDICAL DATA SHEET - THIS MUST BE FULLY COMPLETED
NOTE: If you have ANY changes in your medical condition notify your SSC supervisor immediately.
IN CASE OF EMERGENCY, NOTIFY (This is required for you to attend the SSC)
NAME
RELATIONSHIP
DAYTIME PHONE NUMBER
EVENING PHONE NUMBER
(Include area code)
(Include area code)
MEDICAL HISTORY - (Do you have any of the following? If yes, please explain and list current medications)
NO
YES
IF YES, EXPLAIN
ALLERGIES
IF YES, EXPLAIN
NO
YES
HEART PROBLEMS
IF YES, EXPLAIN
NO
YES
DIABETES
IF YES, EXPLAIN
NO
YES
HIGH BLOOD PRESSURE
NO
YES
IF YES, EXPLAIN
BACK PROBLEMS
IF YES, EXPLAIN
NO
YES
LIFTING RESTRICTIONS
NO
YES
IF YES, EXPLAIN
OTHER (Please specify)
LIST PREVIOUS SURGERIES
PLEASE RETURN THIS FORM BY
JUNE 1.
Tristan Heaton (00SSC)SV
tristan.heaton2@va.gov
RETURN COMPLETED FORMS TO:
VA San Diego HCS
3350 La Jolla Village Dr.
San Diego, CA 92161
(858) 642-6421 Fax (858) 642-6406
0928f
VA FORM
MAR 2012
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