**FINAL DRAFT**

**Cover Page**

**Poster**

  ------------------------------------------------------------ ----------
  **Description**                                              **Page**

  [Welcome from the Richard L. Roudebush VA Acting Medical     3
  Center Director](#DirMess)                                   

  [Welcome from the National Veterans Golden Age Games         4
  Director](#NVGAGDIR)                                         

  [Master Schedule](#_Master_Schedule)                         5

  [General Information](#_General_Information)                 6 - 8

  [Lodging Information](#_Lodging_Information)                 9

  **Competitor Forms**                                         

  [Competitor Registration                                     10
  Checklist](#_Competitor_Registration_Checklist)              

  [Form A: Competitor Application](#FormA)                     11

  [Form B: Event Selection](#FormB)                            12

  [Form C: Hometown News Release Questionnaire](#FormC)        13 - 14

  [Form D: Waiver and Release of Liability/Publicity           15
  Release](#FormD)                                             

  [Medical Clearance Instructions for                          16
  Participants](#_Medical_Clearance_Instructions)              

  [Form E: Medical Form](#FormE)                               17 - 18

  [Form F: Alternate Activities](#FormF) (for both Competitors 19
  and Non-Competitors)                                         

  **Non-Competitor Forms**                                     

  [Non-Competitor Registration Checklist](#NonCom)             10

  [Form G: Non-Competitor Application](#FormG)                 20
  ------------------------------------------------------------ ----------

[]{#DirMess .anchor}![](media/image1.wmf)DEPARTMENT OF VETERANS AFFAIRS

Richard L. Roudebush VA Medical Center

1481 West Tenth Street

Indianapolis, Indiana 46202

January 22, 2008

Dear 2008 National Veterans Golden Age Games Competitors:

On behalf of the Richard L. Roudebush VA Medical Center and the Veterans
in Partnership Network, it is my honor and pleasure to invite you to
participate in the 22^nd^ National Veterans Golden Age Games (NVGAG)
taking place in Indianapolis, Indiana, August 20-24, 2008.

Indianapolis is the nation\'s 13th largest city and is the perfect
balance of cosmopolitan style and small-town charm. Indianapolis is
commonly referred to as the Crossroads of America and is easily
accessible from a wide variety of locations, with many interstate
highways bisecting our city. Not only that, but half the nation\'s
population is within a day\'s drive, which makes traveling to
Indianapolis by car an attractive option for many. Downtown Indianapolis
offers much to do all within a few blocks to include shopping, dining,
and recreation opportunities.

We have many exciting venues for the sporting events such as the Major
Taylor Velodrome, the Indiana University Natatorium, the Indiana
University/Purdue University Indianapolis Michael A. Carroll Track &
Field Stadium, the American Legion Mall, the Indianapolis Convention
Center, and a challenging tree lined golf course along the scenic White
River near downtown Indianapolis.

We would like to express our appreciation for the support and generosity
of the 2008 NVGAG sponsors: the Department of Veterans Affairs, the
Veterans Canteen Service and Help Hospitalized Veterans. Additionally,
thanks to a grant from the Lilly Endowment Inc., Indianapolis,
competitors will be offered enhanced alternate activities and many other
extras.

Enclosed is the 2008 registration packet. We are offering an exciting
alternative which is secure, online registration with which you will
receive your confirmation sooner and ensure you reserve your place in
the games. Because incomplete applications will be returned, you may
wish to have your local VA Recreation Therapy staff or coach help you
fill it out. If you have questions or need more information, please call
our administration team at (317) 988-2747.

Come to Indianapolis and *Race for the Gold* at the 2008 National
Veterans Golden Age Games.

Kenneth Klotz, Jr., MD

Acting Medical Center Director

[]{#NVGAGDIR .anchor}![](media/image2.wmf){width="7.675in"
height="10.190972222222221in"}

***2008 National Veterans Golden Age Games***

***Indianapolis, IN***

**Tuesday, August 19, 2008**

All Day Arrival of athletes, coaches, staff Downtown Indianapolis

**Wednesday, August 20, 2008**

8:00 a.m. -- 5:00 p.m. Registration/Check-in Convention Center, East
Maryland Lobby

7:00 p.m. -- 9:00 p.m. Opening Ceremony Convention Center, Sagamore
Ballroom

9:00 p.m. -- 11:00 a.m. Dance Convention Center, Sagamore Ballroom

**Thursday, August 21, 2008**

8:00 a.m. -- 2:00 p.m. Golf- 18 Holes Coffin Golf Course

8:00 a.m. -- 5:00 p.m. Checkers Convention Center, Wabash Ballroom 1 & 2

8:00 a.m. -- 4:00 p.m. Bowling Western Bowl

1:00 p.m. -- 4:00 p.m. Cycling Practice Major Taylor Velodrome

6:30 p.m. -- 9:30 p.m. Cycling: 667 Meter & 1 Kilometer Major Taylor
Velodrome

8:00 p.m. -- 11:00 a.m. Dance Convention Center, Sagamore Ballroom

**Friday, August 22, 2008**

8:00 a.m. -- 5:00 p.m. Croquet American Legion Mall

8:00 a.m. -- 5:00 p.m. Table Tennis Convention Center, Hall C

8:00 a.m. -- 5:00 p.m. Shuffleboard Convention Center, Hall C

10:00 a.m. -- Noon Tour of Speedway Indianapolis Motor Speedway

2:00 p.m. -- 4:00 p.m. Tour of Speedway Indianapolis Motor Speedway

3:00 p.m. -- 5:00 p.m. Medal Ceremony Convention Center, Wabash Ballroom
1 & 2

7:00 p.m. -- 9:00 p.m. VCS Bingo Convention Center, 500 Ballroom

9:30 p.m. -- 11:00 a.m. Dance Convention Center, 500 Ballroom

**Saturday, August 23, 2008**

8:00 a.m. -- 5:00 p.m. Nine Ball Convention Center, Hall C

8:00 a.m. -- 5:00 p.m. Horseshoes American Legion Mall

8:00 a.m. -- 5:00 p.m. Dominoes Convention Center, Hall C

10:00 a.m. -- Noon Tour of Speedway Indianapolis Motor Speedway

2:00 p.m. -- 4:00 p.m. Tour of Speedway Indianapolis Motor Speedway

3:00 p.m. -- 5:00 p.m. Medal Ceremony Convention Center, Wabash Ballroom
1 & 2

5:00 p.m. -- 9:00 p.m. Dinner and Evening at the Zoo Indianapolis Zoo

**Sunday, August 24, 2008**

7:30 a.m. -- 10:30 a.m. Shot Put Michael A. Carroll Track & Field, IUPUI

7:30 a.m. -- 10:30 a.m. Discus Throw Michael A. Carroll Track & Field,
IUPUI

7:30 a.m. -- 10:30 a.m. Air Rifle Michael A. Carroll Track & Field,
IUPUI

12:30 p.m. -- 2:30 p.m. Swimming IUPUI Natatorium

3:00 p.m. -- 5:00 p.m. Medal Ceremony Convention Center, Wabash Ballroom
1 & 2

5:00 p.m. -- 7:00 p.m. Closing Dinner Convention Center, Sagamore
Ballroom

7:00 p.m. -- 9:00 p.m. Closing Ceremony Convention Center, Sagamore
Ballroom

**Monday, August 25, 2008**

All Day Departures Downtown Indianapolis

**WHO MUST REGISTER:** All competitors, coaches, support staff, and
volunteers must register. Each individual registering must complete a
separate registration form.

**HOW TO REGISTER:** Registration can be done via the forms included in
this packet or you may register online through a secure system. The
Registration Checklist indicates which forms can be completed online and
included in this packet are instructions for online registration.

**ELIGIBILITY:** All veterans, ages 55 or older, who currently receive
inpatient or outpatient care from the U. S. Department of Veterans
Affairs.

**Registration is limited to 650 competitors on a first-come,
first-served basis. If your packet is incomplete, you will be contacted
to re-submit missing documents. This will delay your registration.
Please enlist the help of your coaches before mailing your packet.
Online registration is quicker and just as secure!**

> **[NO LATE REGISTRATION PACKETS WILL BE ACCEPTED]{.underline}**

**GAME EVENTS:** All competitors must enter at least
**[two]{.underline}** but no more than **[four]{.underline}** events.
Complete the Event Selection Form B in the registration packet. Events
include: cycling, bowling, checkers, croquet, dominoes, golf,
horseshoes, nine ball, shot put, discus, 10-meter air rifle,
shuffleboard, table tennis, and swimming.

**On-Line Registration may be completed by accessing the following web
links:**

[http://www.2008NVGAG.com](http://www.2008NVGAG.com/)

Or at

<http://www1.va.gov/vetevent/gag/2008/ToCome.cfm>

**AGE CLASSIFICATION:** All age classifications will be determined by
the competitor\'s age as of **August 21, 2008.** There are seven age
classifications:

> **55-59 60-64 65-69 70-74 75-79 80-84 85+**
>
> Competitors will compete by gender in the following events: **Cycling,
> Bowling, Horseshoes, Shot Put, Swimming and Discus**

**CLASSIFICATION:** Non-ambulatory competitors will have a separate
division in the following events:

**Table Tennis Swimming Horseshoes**

**Nine Ball Bowling Shot Put**

**Shuffleboard Discus**

> Visually impaired competitors will have a separate division in the
> following events:
>
> **Bowling Horseshoes Shuffleboard**

**AIR TRAVEL:** Competitors should plan to arrive and depart from the
Indianapolis International Airport, approximately 30 minutes from the
hotels.

**HOTEL:** Hotel reservations and payment are the responsibility of the
traveler. Specific hotel information will be forwarded to competitors
after acceptance of registration.

**TRANSPORTATION:** The Games\' organizers will provide transportation
for arrivals on **Tuesday, August 19, 2008,** between the airport and
hotels between the hours of 6:00 am and 12: 00 midnight. Representatives
of the Games will greet you at the airport. Transportation for all
National Veterans Golden Age Games sponsored events and activities will
also be provided from the hotels. If traveling by air, check with your
local air terminal for the latest update on Transportation Security
Administration (TSA) requirements regarding carry-on items. Competitors
traveling with oxygen will need to make arrangements with the airlines
regarding the transport of oxygen. Coordination of oxygen services are
the responsibility of the competitor.

> Transportation will be provided to the airport for departures on
> **Monday, August 25, 2008** between the hours of 5:00 am and 12:00
> midnight.

**WEATHER:** Indianapolis weather in August is usually warm and sunny
with occasional showers. Temperatures average from the low 90s during
the day to upper 70s at night. [The hotel rooms and areas for indoor
events are all air conditioned.]{.underline} Items to consider bringing
include a light jacket, umbrella, sweater, hat, swimsuit, sunscreen
(**SPF 30 or higher recommended),** insect repellant, sunglasses, and
appropriate clothing for hot temperatures.

**MEDICAL:** Medical assistance will be provided 24 hours a day as part
of the 2008 National Veterans Golden Age Games. Sick call and emergency
medical treatment will be available at the **Hilton Indianapolis
Hotel**. First aid and patient stabilization will be provided at the
events and activities. Ambulances will be called if emergency care is
needed. **Medical assistance is not intended for pre-existing
conditions.** Competitors must bring with them enough medication and
medical supplies to last throughout the Games. **[There are no
provisions for providing replacement medications and medical
supplies.]{.underline}**

**PERSONAL** As whenever you travel, it is recommended you include all
of your health

**DOCUMENTS:** and insurance information as part of your personal travel
documents.

**CONFIRMATION** Once your completed application has been received and
accepted by the

**OF REGISTRATION:** 2008 Games office, a letter of confirmation will be
sent to you. Included with the confirmation letter will be a form for
you to complete regarding your travel itinerary. The travel itinerary
form must be returned by **July 13, 2008.** Additional correspondence
regarding the Games may follow. Please be sure to watch for these items
and read them carefully.

**WALL OF HEROES:** The National Veterans Golden Age Games traditional
"Wall of Heroes" will continue at the Games in Indianapolis! Please send
a photograph in with your registration packet. Photos should depict
competitors (preferably in military uniform) and be 4"x6" or 5"x7" in
size. [Please note that Wall of Heroes photographs will not be
returned]{.underline}.

**MISCELLANEOUS:** Arrival date is Tuesday, August 19, 2008.
Registration for the Games and events will be on Wednesday, August 20,
2008 from 8:00 am to 5:00 pm. Opening Ceremonies are at 7:00 pm on
Wednesday, August 20, 2008.

**NATIONAL SENIOR** The 2008 National Veterans Golden Age Games is a
qualifying year for the

**GAMES** 2009 National Senior Games. This will allow those competitors
who finish first, second, or third place in the respective qualifying
events and meet National Senior Games standards to become eligible to
compete at the National Senior Games in Palo Alto, California in 2009.
The qualifying events include: Golf, Bowling, Horseshoes, Shuffleboard,
Table Tennis, Shot Put, Discus and Swimming (50 yard Freestyle and 50
Yard Backstroke). The National Senior Games uses the rules provided by
the governing body of their respective sports. The rules are not adapted
in any way. Veterans who qualify for the 2009 National Senior Games will
be responsible for all costs/expenses related to their participation in
the 2009 National Senior Games.

###### PLEASE FEEL FREE TO MAKE ADDITIONAL COPIES OF THIS REGISTRATION PACKET 

**Lodging**: The 2008 National Veterans Golden Age Games will be held in
Indianapolis, Indiana. After receipt of your completed registration
packet, you will receive a letter of confirmation with further
instructions for making hotel reservations. You will be responsible for
making your reservations by contacting the hotel as listed on your
confirmation. Please specify your need for a handicap accessible room,
if applicable, when completing your reservations. THE HOTELS WILL NOT
ACCEPT RESERVATIONS PRIOR TO YOUR RECEIPT OF YOUR LETTER OF
CONFIRMATION.

**Hotel Rates:** The hotel rates are the government rate (\$97.00/Night)
for Indianapolis. The hotels accept all major credit cards.

**Hotel**

**Reservation**

**Deadline**: July 20, 2008: 5:00 p.m. Eastern Standard Time

**Meals**: Meals are furnished at no cost to all 2008 NVGAG competitors.
Meals will be at each competitor's convenience through the use of debit
cards. These cards will be funded/loaded with daily per diem and
competitors will be able to use the card to purchase meals either at
their hotel or at any restaurant that accepts credit cards.

**NVGAG WEBSITE:** The NVGAG Website can be found on the internet at:

<http://www1.va.gov/vetevent/gag/2008/>

**EVENT RULES:** The NVGAG event rules can be found on the Internet at:

<http://www1.va.gov/vetevent/gag/2008/docs/2008NVGAG_Rules_Revised121707.pdf>

> **For further information or if you have questions, contact the 22^nd^
> NATIONAL VETERANS GOLDEN AGE GAMES Office:**
>
> Julie Jackson or Susan Klippel, Administration Sub Committee
>
> National Veterans Golden Age Games
>
> Richard L. Roudebush VA Medical Center
>
> 1481 West Tenth Street
>
> Indianapolis, IN 46202
>
> [By email at]{.underline}:
>
> Julie.Jackson@va.gov

Please ask your coach or medical center staff to review this checklist
with your attached forms prior to mailing.

**REGISTRATION DEADLINE IS June 1, 2008**

Name:

**COMPETITOR FORMS**

> Competitor Application (Form A) Online Paper
>
> Event Selection (Form B) Online Paper
>
> Hometown News Release Questionnaire (Form C) Online Paper
>
> Waiver and Release of Liability / Publicity Release (Form D) **PAPER
> ONLY**
>
> General Medical Information (Form E) **PAPER ONLY**

Current EKG Report

> Current Medication Profile
>
> Alternate Activities for IMS Track Tour Selection (Form F) Online
> Paper

[]{#NonCom .anchor}**NON COMPETITOR FORMS**

> Non-Competitor Application (Form G) Online Paper
>
> Alternate Activities IMS Track Tour Selection (Form F) Online Paper

**\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

**On-Line Registration may be completed by accessing the following web
links:**

[http://www.2008NVGAG.com](http://www.2008NVGAG.com/)

Or at

<http://www1.va.gov/vetevent/gag/2008/ToCome.cfm>

> Non-Competitors will be on their own for meals which will allow them
> the opportunity to join the competitors for meals at the restaurant of
> their selection. No funds will be sent to the medical center and
> non-competitors can pay for meals on an as consumed basis. White River
> State Park passes will likewise be available for non-competitors to
> purchase in Indianapolis.

**COMPETITOR INFORMATION**

Last Name: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ First Name:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ MI: \_\_\_\_

Male Female

Date of Birth: \_\_\_\_\_\_\_ / \_\_\_\_\_\_\_ / \_\_\_\_\_\_\_ Your Age
as of August 21, 2008: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

## DIVISION: Ambulatory Wheelchair Visually Impaired (Legally Blind)

If you are a member of a Veterans Service Organization, indicate that
organization \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

## Please indicate your t-shirt size: Small Medium Large XL XXL XXXL 

Primary VA Medical Center:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_Team Coach:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Telephone \# of Team Coach
(regular):\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ during the games
(cell) \_\_\_\_\_\_\_\_\_\_\_\_\_\_

**Your** Street Address:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ City:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

State: \_\_\_\_\_\_\_\_\_\_ Zip: \_\_\_\_\_\_\_\_\_\_ Email Address:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Day Phone: ( ) \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Cell Phone: (
) \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**[WHEELCHAIR/SCOOTER INFORMATION]{.underline}** (Please provide the
following information about your wheelchair and/or scooter. This
information can be obtained from your Prosthetics Department.)

Are you able to able to ambulate short distances without assistance? Yes
No

Manufacturer: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Model/Make:
\_\_\_\_\_\_\_ Serial Number: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Type: Power Manual Frame Type: Rigid Folding

Camber: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Weight:
\_\_\_\_\_\_\_\_\_\_\_\_\_ Overall Width: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Seat Height: \_\_\_\_\_\_\_\_\_\_\_\_\_ Seat Width:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Seat Depth: \_\_\_\_\_\_\_\_\_\_

Front Wheel/Caster Type: Wheel Caster Height: \_\_\_\_\_ Width:
\_\_\_\_\_ Tire Size: \_\_\_\_\_

Back Wheel/Caster Type: Wheel Caster Height: \_\_\_\_\_ Width:
\_\_\_\_\_ Tire Size: \_\_\_\_\_

Wheelchair/cart Inspected by: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Telephone Number: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

***It is your responsibility to have your wheelchair/scooter inspected
by a VA prosthetic specialist and/or designee before arrival at the
Games to insure that your equipment is in good working order.***

Do you have a service dog? Yes No

**ASSISTIVE EQUIPMENT**- All competitors are encouraged to bring their
own assistive equipment (shower benches, commode chairs, etc.). A
limited number of such equipment will be available on a first-come,
first-served basis during the Games. Please indicate the items needed
along with style, model numbers, etc., and we will try to accommodate
you: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

*Because of the growing numbers of competitors, we cannot prepare a news
release on your participation in the Games if you do not fill out this
form completely. This form gives us the specific information we need to
prepare a news release to distribute to media outlets where you live. We
have simplified it as much as possible, so it is very easy to fill out.
If you have any questions, please call Jenny Tankersley Ballou at (757)
728-3450.*

1.  Your
    Name:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

2\. Date of Birth: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Email Address:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

3\. Please confirm your branch of service.

> Army Army Air Corps Navy Marine Corps
>
> Air Force Coast Guard National Guard Other
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

4\. If you are a peace-time veteran, where and when did you serve?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

5\. a. Did you ever serve in combat? Yes No

> b\. Where did you serve in combat?
>
> World War II (European Theater) Korean War Gulf War
>
> World War II (Pacific Theater) Vietnam Other
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> c\. Were you injured in combat? Yes No
>
> d\. Were you ever held as a POW? Yes No If yes, where?
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

6\. Are you a member of a Veteran Service Organization (VSO)? Yes No

If Yes, which Veteran Service Organization(s)?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

7\. What VA medical facility do you represent (city and state)?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**Please note: All event results will be posted on the Games Web site by
competitor name unless you check the "no" box here:** No **(Your results
will not be posted. Complete question 8 and sign below)**

3.  a\. Do you want us to prepare a news release about your competition
    in the National Veterans Golden Age

Games? Yes No **If you marked "no," please sign under 8b below. You are
done with Form C. You will not receive a photo of your participation.**

b\. If you marked "yes" to a news release in 8a, please provide the
following information, sign below, and then complete questions 9-12.

> I give permission for my phone number to be included in my news
> release posted on the Games Web site.
>
> I do not want my phone number listed on my news release. Media may
> contact me through the Games Public Affairs Coordinator, Jenny
> Tankersley Ballou.
>
> (Signature)\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> **If you wish to have a news release, please answer questions 9-12.**

9.  What are the nearest DAILY and WEEKLY newspapers to your home? (If
    you don't know the name, please give the closest large city, or the
    county that you live in.)

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Name (Please print) City

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Name (Please print) City

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Name (Please print) City

10. **YOUR QUOTE FOR THE NEWS RELEASE**: (This is mandatory.) All we
    need are a few thoughts from you telling us such things as how you
    feel about the Games, what NVGAG competition has done for your life,
    how many times you've competed, what you have looked forward to the
    most, why staying active is important, what you hope to achieve,
    favorite event etc. *(Just give us a few ideas and we'll take it
    from there!)*

*\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_*

*\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_*

*\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_*

*\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_*

*\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_*

1.  Which years have you participated in the NVGAG:

1985 1987 1988 1990 2007 1991 1992 1993 1994 1995 1996 1997 1998 1999
2000 2001 2002

2003 2004 2005 2006

12\. Please describe your favorite Games memories.
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

***Thank you!***

**Read before Signing**

**RELEASE OF LIABILITY:**

In consideration of being allowed to participate in the 2008 National
Veterans Golden Age Games, related events, and activities, I, the
undersigned, acknowledge, appreciate, and agree that:

1.  The risk of injury from the activities involved in these Games is
    significant, including the potential for serious bodily injury,
    including death, and property damage. I KNOWINGLY AND VOLUNTARILY
    ASSUME ALL SUCH RISKS, BOTH KNOWN AND UNKNOWN, and assume full
    responsibility for my participation.

2.  I willingly agree to comply with the stated and customary terms and
    conditions for my participation. If, however, I observe any unusual
    significant hazard during my presence or participation, I will
    remove myself from participation and bring such to the attention of
    the nearest official immediately.

3.  I, for myself and on behalf of my guardians, executors, heirs,
    assigns, personal representatives, and administrators, HEREBY
    RELEASE, HOLD HARMLESS, COVENANT NOT TO SUE, AND FOREVER DISCHARGE,
    the United States Government; the Veterans Canteen Service, Help
    Hospitalized Veterans; their officers, directors, officials,
    members, agents, and employees; and any and all sponsoring agencies,
    sponsors, advertisers, owners, and lessors of premises used to
    conduct the Games, related events, and activities; and, officials,
    volunteers, and other participants of the 22nd National Veterans
    Golden Age Games, from any and all liability, claims, demands,
    actions, and causes of action whatsoever arising out of or related
    to any and all injury, disability, death, or loss or damage to
    person or property.

4.  I consent to medical treatment in the case of emergency. I agree to
    assume full responsibility for payment of any and all fees incurred
    as a result of such medical treatment.

I HAVE READ THIS ASSUMPTION OF RISK AGREEMENT, FULLY UNDERSTAND ITS
TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT,
AND SIGN IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT.

Signature:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Date Signed: \_\_\_\_\_/\_\_\_\_\_\_\_/\_\_\_\_\_\_

Name (Please Print):
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**IN CASE OF EMERGENCY, NOTIFY:**

Name: Phone Number: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Address:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_

Street City State Zip Code

Relationship: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

######### **RELEASE OF PICTURE/VOICE RECORDINGS AND/OR INFORMATION:** 

I voluntarily and without compensation authorize pictures and/or voice
recording(s) to be made of me by or on behalf of the Department of
Veterans Affairs (VA), Veterans Canteen Service, Help Hospitalized
Veterans, U.S. military publications, and other magazines, veterans'
publications, newspapers, and broadcast media, etc., while I am a
participant in the 22nd National Veterans Golden Age Games. I authorize
any or all of the above to publicize and/or display such photographs and
recordings, or to provide such photographs and recordings to others of
their choosing for display, without notice or payment of any royalty,
fee, or other compensation of any character to me for the use of my
picture and/or voice. I understand that the said picture(s) and/or voice
recording(s) are intended to publicize and give recognition to the
National Veterans Golden Age Games. I also authorize storage of my
registration and event data in the electronic media. In the event that I
qualify to participate in the 2009 National Senior Games, I authorize VA
to release my name and address to the National Senior Games Association.

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

You must be seen by your VA Primary Care Provider to be medically
cleared to participate in the Games.

Reminder: We will not provide routine medical care, replacement
medications, replacement equipment or replacement supplies for
pre-existing conditions. You must bring enough medication and medical
supplies to last throughout the games. Any medication or medical
supplies provided on site will be charged back to your medical facility.
We will not refill any narcotic prescriptions.

Competitors using oxygen must have their sponsoring VA Medical Center
coordinate oxygen services, including supplies, with a local oxygen
provider.

We will provide medical assistance 24 hours a day at the Triage Clinic
in the Hilton Indianapolis Hotel. We will also provide first aid and
medical stabilization at the events and activities. Ambulance care will
be provided as needed.

When you check-in for the Games, you must tell us if there have been any
significant changes in your health since you completed your application.
These include:

-   Changes in medication

-   Admissions/Hospitalizations

-   New diagnosis, problems, or conditions

We need current addresses and phone numbers for:

-   You

-   Next of Kin

-   Emergency Contact Person

-   Your Primary Care Provider

-   Sponsoring Facility Point of Contact

Have your VA Primary Care provider complete the enclosed General Medical
Information/Medical Form (Form E) enclosed in this packet.

***A physician, nurse practitioner or physician assistant
[must]{.underline} fill out and sign this form.***

Dear Provider: Pending your approval, your veteran plans to participate
in various athletic events and/or games which may be strenuous and/or
dangerous depending on his/her condition. Additionally, should your
veteran require personal ADL assistance, please understand this will not
be provided by the Richard L. Roudebush VA Medical Center and would be a
reason not to clear him/her unless he/she is accompanied by a caregiver.

**All fields require an answer. If any question does not apply to this
veteran please indicate "NA."**

Veteran's Name:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Today\'s Date: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Last First

SSN:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Veteran's Date of Birth:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Age:\_\_\_\_\_\_

PLEASE REVIEW VETERAN DEMOGRAHICS FOR ACCURACY BEFORE YOU COMPLETE THIS
FORM

Height:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Weight:\_\_\_\_\_\_\_\_\_\_\_\_\_ Blood
Pressure:\_\_\_\_\_\_\_\_\_\_\_\_

PROBLEM LIST (Active Problems): COPD Heart Failure Hypertension Diabetes

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

I have reviewed the above active problems and confirm that this list is
current. Yes No

All Active Medications:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

I have reviewed the above medications and the veteran is taking them as
directed. Yes No

LAST ADMISSION: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Allergies:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Vision: Is the veteran visually impaired (legally blind)? Yes No

Hearing: Is the veteran hearing impaired? Yes No

Tetanus Toxoid Date: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Please update
Tetanus if not within 10 years. Yes No \_\_\_

PPD date: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ within 12 months: Yes
No

If positive, send current x-ray report: Yes No

Can he/she take his/her own medications? Yes No

**Please advise veteran of their responsibility for bringing enough
medication for the trip and the week**.

**RICHARD L. ROUDEBUSH VA MEDICAL CENTER WILL NOT PROVIDE NARCOTIC
REFILLS FOR ANY REASON.** The cost of any medical expenses and/or
medications will be charged back to the veteran or the veteran's
originating facility.

**Veteran's Name:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

**Special Needs:**

Does the veteran need assistance with the following ADLs?

a\. Ambulation Yes No b. Transfer Yes No c. Feeding Yes No

d\. Grooming Yes No e. Toileting Yes No

Is the veteran incontinent of urine? Yes No Is the veteran incontinent
of bowel? Yes No

If the veteran uses a wheelchair, can he/she transfer without
assistance? Yes No

Durable medical equipment or special assistive devices the veteran will
be using:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Is the veteran on portable oxygen? Yes No If yes, Rx: i.e., 2L/min.
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

List special needs: (e.g. feeding tube, tracheotomy, catheter, mobility,
bowel and bladder care, etc.)

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

List those needs that the veteran requires assistance with:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Behavioral Needs:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Cognitive Needs:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

What activity restrictions do you recommend?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**Event Participation**: The veteran is physically capable of
participating in these aerobic events:

a\. Cycling Yes No b. Swimming Yes No

Please select Yes or No by the events the veteran can or cannot
participate in:

Air Rifle Yes No Bowling Yes No Checkers Yes No

Croquet Yes No Discus Yes No Dominoes Yes No

Golf Yes No Horseshoes Yes No Nine Ball Yes No

Shot Put Yes No Shuffleboard Yes No Table Tennis Yes No

In your opinion, can the veteran make the trip and participate in the
National Veterans Golden Age Games?

Yes No

Does the veteran have an Advanced Directive: Yes No

**Provider's Name (Please Print)
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

**Provider's Signature**:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**Please provide a telephone number and a pager number where you can be
reached August 19-**

**August 25, 2008:**
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

> Name:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> I am a (circle one): **Competitor Coach/Staff** **Family
> Member/Guest**
>
> Tour the Indianapolis Motor Speedway -- **free** to competitors.
> Non-competitors may purchase tickets at the Speedway the day of the
> event for \$6.00 each.
>
> If interested, please check the **date and time** that would work best
> for you. Please ensure this activity does not conflict with your event
> schedule.
>
> **[Friday, August 22, 2008]{.underline}**
>
> 10:00 am -- 12:00 Noon Tour of Indianapolis Motor Speedway
>
> 2:00 pm -- 4:00 pm Tour of Indianapolis Motor Speedway
>
> **[Saturday, August 23, 2008]{.underline}**
>
> 10:00 am -- 12:00 Noon Tour of Indianapolis Motor Speedway
>
> 2:00 pm -- 4:00 pm Tour of Indianapolis Motor Speedway
>
> **This form must be returned if you are interested in the "Tour of
> Indianapolis Motor Speedway"**
>
> Are you able to board a bus/van without using a wheelchair/scooter?
> Yes
>
> No
>
> The White River State Park Pass will be **free** to competitors and
> includes a ticket to each of the following attractions: the Eiteljorg
> Museum of American Indians and Western Art, IMAX Theater, Indiana
> State Museum, Indianapolis Zoo/White River Gardens, NCAA Hall of
> Champions and Congressional Medal of Honor Memorial. Busses will
> provide transportation during competition days on a continuous loop,
> allowing you to determine what activity you do as you are available.
> Non-competitors may purchase a pass for \$40.50. Details on how to
> purchase the pass will be available during registration. If individual
> tickets are needed, they may be purchased at the White River State
> Park.

![](media/image3.jpeg){width="2.1041666666666665in"
height="1.5208333333333333in"}

Please check only one: Coach Support Staff Family/Significant Other

Last Name: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ First
Name:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ MI:\_\_\_\_\_\_

Street Address:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

City: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ State:
\_\_\_\_\_\_\_\_\_\_\_\_\_ Zip:\_\_\_\_\_\_\_\_\_

Day Phone: ( ) \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Cell Phone: ( )
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Email Address:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

What VA Medical Center do you represent?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Do you use a wheelchair or scooter? No Yes

**In Case Of Emergency, Notify:**

Name: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Phone
Number: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Address: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_

Street City State Zip Code

Relationship:

**For coaches only**, does your team have a name? No Yes

Name of Team:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Please list of your team member's names:

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**For coaches and support staff,** please indicate your t-shirt size:

## Small Medium Large XL XXL XXXL Other

**Release of Picture/Information:** I voluntarily and without
compensation authorize photograph(s), video(s), and voice recording(s)
to be made of me by or on behalf of the Department of Veterans Affairs
(VA), the Veterans Canteen Service, Help Hospitalized Veterans, US
military publications, community media outlets, etc., while I am
attending the 22^nd^ National Veterans Golden Age Games. I authorize any
or all of the above to publicize and/or display such photographs and
recordings, or to provide such photographs and recordings to others of
their choosing for display, without notice or payment of any royalty,
fee, or other compensation of any character to me for the use of my
picture and/or voice. I understand that the said picture(s) and/or voice
recording(s) are intended to publicize and give recognition to the
National Veterans Golden Age Games. Also, I authorize storage of my
registration and event data in the electronic media.

Signature Date