![](media/image1.jpeg){width="6.573611111111111in" height="10.0in"}

![](media/image2.png){width="2.0597222222222222in"
height="1.4145833333333333in"}**DEPARTMENT OF VETERANS AFFAIRS**

**Medical Center**

**Hampton, Virginia 23667**

> January 10, 1996In Reply Refer To: 590/003
>
> November 9, 2005
>
> Dear 2006 National Veterans Golden Age Games Competitors:
>
> As Director of the Hampton VA Medical Center, it is my honor and
> pleasure to invite you to the 20th National Veterans Golden Age Games,
> *Champions by the Bay*, to be held in Hampton, Virginia, May 7- 12,
> 2006.
>
> The 2006 National Veterans Golden Age Games (NVGAG) is again sponsored
> by the Department of Veterans Affairs, Veterans of Foreign Wars &
> Ladies Auxiliary and Veterans Canteen Service. Because of our location
> at the heart of the founding of this great nation nearly 400 years ago
> and the fantastic venues we offer, it holds the promise of being one
> of the best Games yet for the more than 500 veterans we anticipate
> competing. The VISN 6, Mid-Atlantic Health Care Network Director, Mr.
> Daniel F. Hoffmann, joins me in our committed support to meet and
> exceed your expectations.
>
> The Games continue to be a qualifying event for the National Senior
> Games. We are pleased that we are hosting the NVGAG during a
> qualifying year for the 2007 National Senior Games to be held in
> Louisville, KY.
>
> Enclosed you will find the 2006 registration packet. Please take the
> time to complete it thoroughly. You may wish to have your Chief,
> Recreation Therapy Service and/or Coach assist you with the proper
> completion of the application so that it can be accepted without
> having to be returned to you for more information. You may also wish
> to have a friend, relative or coach help you making sure your quote
> for hometown news (Form E) reflects your true feelings about the Games
> and can be easily pulled for your news release.
>
> If you have any questions or need additional information, please
> contact Jenny Shafer Tankersley or Sandi Dannenberg, Coordinators for
> the 2006 National Veterans Golden Age Games at (757) 728-3450 or (757)
> 722-9961, Ext. 2571.
>
> Whether this is your first National Veterans Golden Age Games or you
> are an annual competitor, we look forward to seeing you in Hampton
> this Spring for the 2006 National Veterans Golden Age Games,
> *Champions By the Bay*!
>
> Sincerely Yours,
>
> ![](media/image3.png)
>
> JOSEPH A. WILLIAMS, JR.
>
> Director, Hampton VA Medical Center

![](media/image4.jpeg){width="1.25in" height="1.25in"}

**Office of the Director**

**National Veterans Golden Age Games**

**50 Irving St. NW**

**Washington, DC 20422**

> Dear 2006 National Veterans Golden Age Games Participants:
>
> The staff and volunteers of the Hampton VA Medical Center have worked
> hard over the past year and a half, planning and implementing a
> National Veterans Golden Age Games (NVGAG) that you will enjoy. They
> have taken extra steps to ensure that the venues for each event will
> be the championship quality you expect and deserve.
>
> We have renewed our relationship with the National Senior Games
> Association. This will allow those who finish first or second in their
> respective qualifying events and meet Senior Olympic standards to
> become eligible to compete at the Senior Olympics in Louisville,
> Kentucky in 2007.
>
> I want to congratulate our veteran qualifiers who competed in the 2005
> Senior Olympics in Pittsburgh, Pennsylvania this past summer. They
> held their own against many athletes that were ranked nationally and
> internationally in their respective age groups and events. Our veteran
> participants did exceptionally well and made all of us proud. We hope
> that many more of you take advantage of this opportunity to qualify in
> 2006.
>
> Per many of our veteran's requests, we have split the 80+ age group
> into two age groups- an 80 to 84 age group and an 85 and up age group.
> This reinforces that many of you are leading healthier lifestyles
> through sports and fitness. Although some veterans have asked us to
> add a 50 to 54 age group, we cannot do so at this time. With over 500
> veterans competing in the National Veterans Golden Age Games, adding
> the 50 to 54 age can not be accomplished due to funding constraints.
>
> I want to encourage many of you to take part in some of the special
> activities at the years NVGAG. For those who like to golf or might be
> interested in learning or improving their game, a golf clinic will be
> held immediately after the golf competition on Monday morning. Local
> pros will be on hand to provide instruction. We have also added a 1500
> meter race walk exhibition event which will be held on Thursday
> evening. If enough veterans are interested, we may add this event to
> the 2007 NVGAG. The Hampton VA staff has created an electronic medical
> clearance form, should your primary VA care facilities choose to use
> it. Instructions for use can be found at the 2006 NVGAG web site at:
>
> <http://www.veteransgoldenagegames.org/>.
>
> Best of luck with your practice and training for the 20^th^ National
> Veterans Golden Age Games. We look forward to seeing all of you May 7
> through 12, 2006 in Hampton, Virginia at "Champions by the Bay".
>
> Sincerely,
>
> ![](media/image5.png){width="2.501388888888889in"
> height="0.5854166666666667in"}
>
> DEWAYNE C. VAUGHAN, Director
>
> National Veterans Golden Age Games

![](media/image6.jpeg){width="4.597222222222222in" height="0.5in"}

SPONSORED BY THE DEPARTMENT OF VETERANS AFFAIRS • VETERANS OF FOREIGN
WARS • VETERANS CANTEEN SERVICE

> AND LADIES AUXILIARY

**2006 National Veterans Golden Age Games Schedule**

  ---------------- ------------------------ -----------------------------
  **Saturday May                            
  6, 2006**                                 

  All Day          Arrivals                 Hampton, VA

  2:00 pm --       Air Power Over Hampton   Langley Air Force Base
  Closing          Roads                    

  **Sunday May 7,                           
  2006**                                    

  8:00 am -- 5:00  Registration             Hampton Roads Convention
  pm                                        Center

  2:00 pm --       Air Power Over Hampton   Langley Air Force Base
  Closing          Roads                    

  Afternoon        Antique Car Show         Hampton Roads Convention
                                            Center

  7:00 pm          Opening Ceremonies       Hampton Roads Convention
                                            Center

  9:00 pm -- 12:00 Dance                    Hampton Holiday Inn- Atrium
  am                                        

  **Monday May 8,                           
  2006**                                    

  7:30 am -- Noon  Colonial Williamsburg    Williamsburg, VA

  8:00 am -- Noon  Golf                     Woodlands Golf Course

  11:00 am -- Noon Golf Clinic              Woodlands Golf Course

  8:00 am -- 5:00  Checkers                 Clarion Hotel -- Hampton
  pm                                        Ballroom

  12:00 pm -- 6:00 Jamestown Settlement     Jamestown, VA
  pm                                        

  2:00 pm -- 5:00  Bicycling                Fort Monroe
  pm                                        

  6:30 pm -- 9:00  Bass Pro Shop            Hampton, VA
  pm                                        

  9:00 pm -- 12:00 Dance                    Hampton Holiday Inn- Atrium
  am                                        

  **Tuesday May 9,                          
  2006**                                    

  8:30 am -- 5:00  Bowling (Ambulatory)     Spare Times Bowling Center
  pm                                        

  8:30 am -- 5:00  Bowling (W/C & VI)       Fort Monroe
  pm                                        

  8:30 am -- Noon  Swimming                 YMCA

  9:30 am -- Noon  Botanical Gardens        Norfolk, VA

  12:30 pm -- 4:00 Air & Space Museum       Hampton, VA
  pm                                        

  5:00 pm -- 12:00 Bash by the Bay          Hampton, VA
  am                                        

  **Wednesday May                           
  10, 2006**                                

  8:00 am -- 5:00  Croquet                  Darling Stadium
  pm                                        

  8:00 am -- 5:00  Horseshoes               Hampton VA Medical Center
  pm                                        

  8:00 am -- 5:00  Dominoes                 Clarion Hotel -- Hampton
  pm                                        Ballroom

  8:00 am -- Noon  Nauticus                 Norfolk, VA

  12:30 pm -- 5:00 USS Wisconsin            Norfolk, VA
  pm                                        

  7:00 pm -- 9:00  Veterans Canteen Service Holiday Inn Hotel- Regency
  pm               Bingo                    Ballroom

  9:00 pm -- 12:00 Dance                    Hampton Holiday Inn- Atrium
  am                                        

  **Thursday May                            
  11, 2006**                                

  8:00 am -- 5:00  Nine Ball                Hampton Roads Convention
  pm                                        Center Exhibit Hall B

  8:00 am -- 5:00  Shuffleboard             Hampton Roads Convention
  pm                                        Center Exhibit Hall A

  8:00 am -- 5:00  Table Tennis             Hampton Roads Convention
  pm                                        Center Exhibit Hall B

  8:00 am -- Noon  Yorktown Victory Center  Yorktown, VA

  12:00 pm -- 5:00 Victory Rover Boat       Norfolk, VA
  pm               Cruise                   

  6:30 pm -- 9:00  Bass Pro Shop            Hampton, VA
  pm                                        

  7:00 pm -- 9:00  Race Walk Exhibition     Darling Stadium
  pm                                        

  9:00 pm -- 12:00 Dance                    Hampton Holiday Inn- Atrium
  am                                        

  **Friday May 12,                          
  2006**                                    

  8:00 am -- 11:00 Air Rifle                Fort Monroe
  am                                        

  8:00 am -- 11:00 Shot Put                 Fort Monroe
  am                                        

  8:00 am -- 11:00 Discus                   Fort Monroe
  am                                        

  8:00 am -- Noon  Virginia Beach           Virginia Beach, VA

  12:00 pm -- 6:00 Virginia Sports Hall of  Portsmouth, VA
  pm               Fame                     

  7:00 pm          Closing Ceremonies       Hampton Roads Convention
                                            Center

  9:00 pm -- 12:00 Dance                    Hampton Holiday Inn- Atrium
  am                                        
  ---------------- ------------------------ -----------------------------

**NATIONAL VETERANS GOLDEN AGE GAMES**

**May 7-12, 2006**

**HAMPTON, VIRGINIA**

> **GENERAL INFORMATION**

**WHO MUST REGISTER:** All competitors, coaches, support staff and
volunteers must register. Each

> individual registering must complete a separate registration form.

**ELIGIBILITY:** All veterans, ages 55 or older, who are currently
receiving

Inpatient or Outpatient care from the Department of Veterans Affairs.

**REGISTRATION DEADLINE:** Completed registration forms must be
postmarked on or before:

**February 28, 2006**

PLEASE RETURN COMPLETED PACKAGE TO:

Sheila Bailey, Registration Chair (11D)

National Veterans Golden Age Games

VA Medical Center

100 Emancipation Drive

Hampton, VA 23667

**Registration is limited to 550 competitors on a first-come
first-served, basis. If your form is incomplete, you will be contacted
to re-submit any missing documents, which will delay your registration.
Please enlist the help of your coach before mailing the packet.**

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

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

**EVENT RULES:** Event rules are available via the Internet at:

[http://www.veteransgoldenagegames.org](http://www.veteransgoldenagegames.org/)

**CLASSIFICATION:** All age classifications will be determined by the
competitor\'s age as of **May 8, 2006**. ***There are now, 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:
> **Bicycling, Bowling, Horseshoes, Shot Put, Swimming and Discus**
>
> Competitors in wheelchairs/scooters will have a separate division in
> the following events: **Table Tennis, Swimming, Horseshoes, Nine Ball,
> Bowling, Shot Put, Shuffleboard and Discus**

Competitors with visually impairments will have a separate division in
the

following events: **Bowling, Horseshoes and Shuffleboard**

**AIR TRAVEL:** Competitors may travel into Hampton by either the
Norfolk International Airport in Norfolk, Virginia or Newport
News/Williamsburg Airport in Newport News, Virginia. Both airports are
approximately 20 minutes from the hotels

**GENERAL INFORMATION, continued**

**HOTEL:** Hotel reservations and payment are the responsibility of the
traveler. Specific hotel information can be found in the **Lodging
Information** section of the registration packet.

**TRANSPORTATION:** The Games\' organizers will provide transportation
for arrivals on **Saturday, May 6, 2006** between the airports and
hotels. 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.

> Transportation will be provided to the airports for departures on
> **Saturday, May 13, 2006.**

**WEATHER:** Hampton's weather in May is usually mild and sunny with
occasional showers, with average temperatures ranging in the high 70s
and lows in the mid to upper 50 degree range. [The hotel rooms and areas
for indoor events are all air-conditioned.]{.underline} Items to
consider bringing include a light jacket, sweater, hat, swimsuit,
sunscreen, sunglasses, and appropriate clothing for moderate to warm
temperatures.

**MEDICAL:** Medical assistance will be provided 24 hours a day as part
of the 2006 National Veterans Golden Age Games, *Champions By the Bay*.
Sick call and emergency medical treatment will be coordinated at the
**Holiday Inn**. First aid and patient stabilization will be provided at
the events, activities and alternate hotel sites. Ambulances will be
called if emergency care is needed.

> **[AS A REMINDER, MEDICAL ASSISTANCE IS NOT INTENDED FOR PRE-EXISTING
> CONDITIONS.]{.underline}**
>
> 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 DOCUMENTS:** As whenever you travel, it is recommended that
you include all of your health related

> and insurance information as part of your personal travel documents.

**CONFIRMATION**

**OF REGISTRATION:** Once your completed application has been received
and accepted by the 2006 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 April 1, 2006.

**GENERAL**

**INFORMATION:** Arrival date is **Saturday, May 6**, **2006**. Dinner
will be provided on Saturday evening. Registration for the Games and
events will be on **Sunday, May 7, 2006** from 8 am to 4 pm. Opening
Ceremonies is at 7:00 pm on **Sunday, May 7**, **2006**.

**For further information, contact the 20th NATIONAL VETERANS GOLDEN AGE
GAMES Office:**

> **Hampton VA Medical Center**
>
> **National Veterans Golden Age Games**
>
> **Sandi Dannenberg or Jenny Tankersley, Co-Coordinators**
>
> **Telephone: (757) 722-9961, ext. 2571 or 3450**

###### 

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

**REGISTRATION CHECKLIST**

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

**REGISTRATION DEADLINE IS FEBRUARY 28, 2006**

Name: Social Security Number:

**COMPETITOR FORMS**

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

 [Event Selection](#FormD) (Form D)

 [Hometown News Release Questionnaire](#FormE) (Form E)

 [Release of Liability and Publicity Release/Release of
Information](#FormF) (Form F)

 [General Medical Information](#FormG) (Form G)

 Current EKG Report

-   Current Medication Profile

```{=html}
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```
-   [Alternate Activities Checklist](#ALTACT) (Form H)

## 

## 

## FORMS FOR COACHES / SUPPORT STAFF / FAMILY & OTHERS 

-   [Non-competitor Registration Form](#FormC) (Form C)

-   [Meals Form](#FormB) (Form B)

-   [Alternate Activities Checklist](#ALTACT) (Form H)

> **[Make Checks / Money Orders Payable to:]{.underline} VA Medical
> Center Hampton and on the memo line: 2006 NVGAG ACCOUNT GPF 1701.
> Please include your check/money order with your registration packet.**

**Postmark deadline is FEBRUARY 28, 2006.**

**LODGING:** The 2006 National Veterans Golden Age Games, *Champions By
the Bay,* will be held in Hampton, Virginia. Competitors, their families
and coaches will be lodged primarily at the Holiday Inn and the Hampton
Inn, as well as the Clarion Inn (wheelchair accessible)*.* The Holiday
Inn and Hampton Inn have limited handicap bathroom access, with the
Clarion Inn offering all rooms with wheelchair accessibility. All
lodging costs are the responsibility of the participating competitors,
coaches and support staff.

> 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 hotels at the numbers below:

**HOTEL RATES:** **[Holiday Inn]{.underline} (1-800-842-9370**)

\$89.00 + 13% sales tax per night/per room (double/single occupancy)

**[Hampton Inn]{.underline} (1-800-842-9370)**

\$89.00 + 13% sales tax per night/per room (double/single occupancy)

> **[Clarion Inn]{.underline} (1-800-562-8090) [(Wide
> doors)]{.underline}**
>
> Priority for accessible rooms will be given to requests by
> non-ambulatory competitors.

\$89.00 + 13% sales tax per night/per room (double/single occupancy)

> A valid credit card will be REQUIRED to reserve your room.

**RV PARKS:** Newport News Park (approximately 12 miles from Hampton)

> 13564 Jefferson Avenue
>
> Newport News, VA 
>
> 1-800-203-8322
>
> [www.nnparks.com](http://www.nnparks.com/)

**MEALS: [Breakfast, lunch and dinner]{.underline}** will be served at
the Holiday Inn.

Meals are furnished at no cost to all 2006 NVGAG veteran competitors.
Tickets are required for all meals. Meals will be available beginning
with dinner on arrival day, Saturday**, May 6, 2006** and concluding
with breakfast on departure day, Saturday**, May 13, 2006.** The menus
will accommodate special diets including diabetic, vegetarian, etc.
**[Other special diet requests are to be in writing and are to accompany
the registration forms.]{.underline}**

#######  

> **Meal tickets will be issued upon arrival**.
>
> **Coaches, support staff and family members** may purchase a meal
> ticket by the day or week. See Form B -- Meal Information

**COMPETITOR INFORMATION**

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

Male Female Social Security Number - -

Date of Birth: \_\_\_\_\_\_\_ / \_\_\_\_\_\_\_ / \_\_\_\_\_\_\_ Your Age
as of May 8, 2006: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

## 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 number of Team Coach:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

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

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

Day Phone: ( ) \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Evening 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.)

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 participants 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: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ 

## \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ 

Name: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Social Security #: \_\_\_\_\_\_\_/\_\_\_\_\_\_\_/\_\_\_\_\_\_\_

Arrival date: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Departure date: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

## Meals are furnished for all competitors. Coaches, support staff, family members, and others may purchase meal tickets at the costs listed below. 

If you are a non-competitor, will you need a meal ticket? Yes No

If you are purchasing by the day, please indicate the days:

> Saturday 5/6 Dinner Only \$20.00
>
> Sunday 5/7 Three Meals \$43.00
>
> Monday 5/8 Three Meals \$43.00
>
> Tuesday 5/9 Three Meals \$43.00
>
> Wednesday 5/10 Three Meals \$43.00
>
> Thursday 5/11 Three Meals \$43.00
>
> Friday 5/12 Three Meals \$43.00
>
> Saturday 5/13 Breakfast Only \$10.00
>
> ALL MEALS ALL DAYS \$ 288.00
>
> Total \$

Method of payment: Check Money Order

Please make payment to: VA Medical Center Hampton

In the memo please state: **MEALS 06 NVGAG GPF 1701**

#### D

**NON-COMPETITOR INFORMATION**

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

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

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

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

Day Phone: ( ) \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Evening Phone: ( )
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

What VA do you and/or your competitors represent?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Does your team have a name? Yes No If Yes, what
name:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Please provide a list of your team member's names:

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

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

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

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

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

FOR COACHES AND SUPPORT STAFF: Please indicate your T-Shirt size:

Medium Large X Large XX Large XXX Large

**IN CASE OF EMERGENCY, NOTIFY:**

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

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

Street City State Zip Code

Relationship:

######### PUBLICITY RELEASE / RELEASE OF INFORMATION 

I voluntarily and without compensation authorize pictures and/or voice
recording(s) to be made of me by or on behalf of VA, VFW and Ladies
Auxiliary, Veterans Canteen Service, US military publications, and other
magazines, veterans' publications, newspapers, and broadcast media,
etc., while I am attending the 20th 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

# 

# Please make sure that you fill out Form B "Meal Information" prior to submitting your registration form 

![](media/image7.jpeg){width="7.697916666666667in"
height="9.89236111111111in"}

**2006 National Veterans Golden Age Games**

*All competitors must complete questions 1-9. If you would like us to
prepare a news release about your participation in the Games, you must
complete the entire form. 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 at (757) 728-3450.*

1.  Your Name: Home Phone: ( )

2\. Date of Birth: E-Mail Address:

3\. Home Address:

4\. Please indicate your branch of service:

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

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 Veterans of Foreign Wars?

> If Yes, please list Post name or number(s)?
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

7\. Are you a member of any other Veterans Service Organizations (VSO)?
Yes No

> If Yes, which Veterans Service Organization and Post or Chapter
> Number? \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

8\. What VA Medical facility do you represent (city and state)?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

9\. Do you want a news release made available to local media where you
live? Yes No

a\. If you answered "No," sign name here and skip questions 10-12:

Signature\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

b.  If your answer is "Yes," you MUST fill out questions 10-12. If the
    form is not [completely]{.underline} filled out and returned, we
    [cannot]{.underline} produce a news release.

```{=html}
<!-- -->
```
10. Do we have your permission to include your home phone number on your
    news release so your local media can contact you directly? This
    information will appear on the NVGAG website,
    [www.veteransgoldenagegames.org](http://www.veteransgoldenagegames.org/)

> Yes, I give my permission for my phone number to be listed.
>
> No, I do not want my phone number listed.
>
> Signature:
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
> Date:
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

11\. 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.)
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

12. Quote for your news release: What has participating in the National
    Veterans Golden Age Games done for your life? If this is your first
    year, what have you been looking forward to? Why is it important to
    you? Why is staying active important? Have you trained? What's your
    best event? *\[Remember, without a quote, we will not be able to
    produce a release! Continue on the back if more room is
    needed.\]\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_*

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

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

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

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

**RELEASE OF LIABILITY (Read before Signing)**

In consideration of being allowed to participate in the 2006 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 of Foreign Wars; their
    officers, directors, officials, members, agents, and employees; and
    any and all sponsoring agencies, sponsors, advertisers, owners, and
    leasers of premises used to conduct the Games, related events, and
    activities; and, officials, volunteers, and other participants of
    the 20th 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: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

######### TY RELEASE/

######### PUBLICITY RELEASE/RELEASE OF INFORMATION

#########  

I voluntarily and without compensation authorize pictures and/or voice
recording(s) to be made of me by or on behalf of VA, VFW & Ladies
Auxiliary, Veterans Canteen Service, US military publications, and other
magazines, veterans' publications, newspapers, and broadcast media,
etc., while I am a participant in the 20th 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

All competitors must be medically cleared by their providers prior to
participation in the 20^th^ National Veterans Golden Age Games.

Reminder: The Hampton VA Medical Center will not provide routine medical
care, replacement medications, or replacement supplies for pre-existing
conditions. Competitors 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.
Narcotic prescriptions will not be filled.

Bring all medications and medical supplies with you in your **carry-on**
luggage. **Do not** pack medicines in checked luggage as luggage can be
lost or damaged.

Medical assistance will be provided 24-hours a day at the Triage Clinic
in the Holiday Inn. First Aid and medical stabilization will be provided
at the events and activities. Ambulance care will be provided, as
needed.

The following information is required at the time of Check In at the
Medical Stop at the Games:

-   any significant changes in your health since you completed your
    application

-   changes in medication

-   admissions/hospitalizations

-   new diagnosis, problem, or condition

-   Primary Care Provider's name and phone number in effect during the
    week of the Games.

**This year, the National Veterans Golden Age Games requests that you
participate in a Medical Clearance pilot program using an electronic
medical screening form. This electronic form will allow improved access
to your medical information.**

You may choose one of two options.

**Option A:**

Ask your local VA staff (coach, recreation therapist, or social worker)
to have your medical center's Clinical Application Coordinator install
the [Electronic Medical Screening Form]{.underline} by going to the
National Veterans Golden Age Games website at:
<http://www.veteransgoldenagegames.org/>

Have your primary care provider complete the electronic General Medical
Information/Medical Form (Form G). Follow the instructions on the Web
Page.

If you do not choose to participate, you may chose:

**Option B**:

Have your VA Primary Care provider complete the enclosed General Medical
Information/Medical Form (Form G) at the end of this package.

**2006 National Veterans Golden Age Games**

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

Dear Provider: Pending your approval, your patient is planning on
participating in various athletic events and/or games which may be
strenuous and/or dangerous depending on his/her condition. Additionally,
should the patient require personal ADL assistance, please understand
this will not be provided by Hampton VAMC and would be a reason not to
clear him/her unless they are accompanied by a caregiver.

**ALL FIELDS REQUIRE AN ANSWER. IF ANY QUESTION DOES NOT APPLY TO THIS
PATIENT PLEASE ANNOTATE NOT APPLICABLE (N/A).**

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

Last First

SSN:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Patient's birth date:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Age:\_\_\_\_\_\_

PLEASE REVIEW PATIENT DEMOGRAHICS FOR ACCURACY BEFORE YOU COMPLETE THIS
FORM

Height:\_\_\_\_\_\_\_\_\_\_\_\_\_ Weight:\_\_\_\_\_\_\_\_\_\_\_\_\_ Body
Mass Index:\_\_\_\_\_\_\_\_\_\_\_\_\_ Blood
Pressure:\_\_\_\_\_\_\_\_\_\_\_\_\_

PROBLEM LIST ACTIVE:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

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

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 patient 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

Significant Physical Findings: (non-ambulatory, dementia, hemiplegia,
diabetes, severe arthritis, etc.)

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

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

Contact person if injured:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

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

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

**HAMPTON VAMC WILL NOT PROVIDE NARCOTIC REFILLS FOR ANY REASON.**

The cost of any medical expenses and/or medications will be charged back
to the veterans originating facility.

**GENERAL MEDICAL INFORMATION (CONT.)** Page 2

Patient Name:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
SSN:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Last First

**Special Needs**

ADL Needs:

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

d\. Grooming Yes No e. Toileting Yes No

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

If 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

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

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

List those needs that the patient 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\. Bicycling Yes No b. Race Walking Yes No c. Swimming Yes No

Please select Yes or No by the events the patient 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 patient make the trip and participate in the
National Veterans Golden Age Games?

Yes No

Does the veteran have an Advanced Directive: Yes No

VA Primary Care Provider:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Please provide a telephone/pager number where you can be reached May
6-12, 2006: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**2006 NATIONAL VETERANS GOLDEN AGE GAMES**

######## CHAMPIONS BY THE BAY

######## ALTERNATE ACTIVITIES

  

Name:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

I am a (circle one): Competitor Coach/Staff Family Member/Guest

 

Please make your selection by checking the appropriate activity box.

Selection of alternate activities is not to be in conflict with your
event schedule.

Payment for alternate activities is to be received by **February 28,
2006** in order to assure your reservations.

\*\*Payment for Alternate Activities is non-refundable. 

**[Date]{.underline} [Cost]{.underline} [Time]{.underline}**

+-------------------------------------------+--------------------------+
| **Saturday, May 6, 2006**                 |                          |
+-------------------------------------------+--------------------------+
| > Air Power over Hampton Roads Air Show   | > **All Day** (Buses     |
| > \$ 5.00                                 | > running continuously)  |
+-------------------------------------------+--------------------------+
| > **Sunday, May 7, 2006**                 |                          |
+-------------------------------------------+--------------------------+
| > Air Power over Hampton Roads Air Show   | > **All Day** (Buses     |
| > \$ 5.00                                 | > running continuously)  |
+-------------------------------------------+--------------------------+
| > Antique Car Show Free                   | > **Afternoon**          |
+-------------------------------------------+--------------------------+
| **Monday, May 8, 2006**                   |                          |
+-------------------------------------------+--------------------------+
| Colonial Williamsburg \$ 5.00             | > **7:30am-Noon**        |
+-------------------------------------------+--------------------------+
| Jamestown Settlement \$10.00              | > **Noon-6:00pm**        |
+-------------------------------------------+--------------------------+
| Bass Pro Shop Free                        | > **6:30pm-9:00pm**      |
+-------------------------------------------+--------------------------+
| **Tuesday, May 9, 2006**                  |                          |
+-------------------------------------------+--------------------------+
| Botanical Gardens \$ 7.00                 | > **9:30am-Noon**        |
+-------------------------------------------+--------------------------+
| Virginia Air & Space Museum (includes     | > **12:30pm-4:00pm**     |
| IMAX movie) \$12.00                       |                          |
+-------------------------------------------+--------------------------+
| **Wednesday, May 10, 2006**               |                          |
+-------------------------------------------+--------------------------+
| > Nauticus (includes movie) \$10.00       | > **8:00am-Noon**        |
+-------------------------------------------+--------------------------+
| > USS Wisconsin \$ 5.00                   | > **12:30pm-5pm**        |
+-------------------------------------------+--------------------------+
| **Thursday, May 11, 2006**                |                          |
+-------------------------------------------+--------------------------+
| Yorktown Victory Center \$ 7.00           | > **8:00am-Noon**        |
+-------------------------------------------+--------------------------+
| Victory Rover Boat Cruise \$17.00         | > **Noon-5:00pm**        |
+-------------------------------------------+--------------------------+
| Bass Pro Shop Free                        | > **6:30pm-9:00pm**      |
+-------------------------------------------+--------------------------+
| **Friday, May 12, 2006**                  |                          |
+-------------------------------------------+--------------------------+
| Virginia Beach \$ 5.00                    | > **8:00am-Noon**        |
+-------------------------------------------+--------------------------+
| Virginia Sports Hall of Fame \$7.00       | > **Noon-6:00pm**        |
+-------------------------------------------+--------------------------+

Are you able to board a bus/van without using a wheelchair/scooter? Yes
No

2006 NATIONAL VETERANS GOLDEN AGE GAMES

CHAMPIONS BY THE BAY

 **ALTERNATE ACTIVITIES DESCRIPTION**

# AIR POWER OVER HAMPTON ROADS: LANGLEY AIR FORCE BASE AIR SHOW

# 

The air show will feature numerous military and civilian aerial
demonstrations and one of the largest displays of static aircraft from
across the United States. From war-birds to the latest in modern
aviation technology, including the F/A-22, dozens of aircraft will be in
the air and on static display. Significant walking will be required.
Tour will take 3-4 hours -- bus will leave every two hours.

**COLONIAL WILLIAMSBURG**

More than 200 years ago, the pursuit of equality, freedom & independence
began a revolution that continues to shape the world...Welcome to
Colonial Williamsburg -- America Chapter I. With more than 500 restored
and reconstructed buildings spread across 301 acres of land, and a staff
of 3500 archaeologists, researchers, historians, and historical
interpreters, Colonial Williamsburg truly is a different time and place.

Colonial Williamsburg will involve walking and the self guided tour
takes approximately 3 hours. Passes will be available for purchase for
entry into the colonial buildings.

**JAMESTOWN SETTLEMENT**

WILLIAMSBURG, Va. -- In 1607, 13 years before the Pilgrims landed in
Massachusetts, a group of 104 Englishmen began a settlement on the banks
of Virginia\'s James River. They were sponsored by the Virginia Company
of London, whose stockholders hoped to make a profit from the resources
of the New World. The community suffered terrible hardships in its early
years, but managed to endure, earning the distinction of being
America\'s first permanent English colony. Jamestown requires a
significant amount of walking. The tour takes 2-3 hours.

**NORFOLK BOTANICAL GARDENS**

Today, theme gardens include the Bristow Butterfly Garden, the Sarah Lee
Baker Perennial Garden, the Virginia Native Plant Garden and the Four
Seasons Garden. Each of these gardens allows guests to see a variety of
plants-from the cultivated to the wild. Norfolk Botanical Garden
includes 155-acres, with over 20 theme gardens that can be viewed by
tram, boat or by foot. Tour takes 2-3 hours.

**VIRGINIA AIR & SPACE MUSEUM**

Take flight to the Virginia Air & Space Center, the visitor center for
[NASA Langley Research Center](http://www.larc.nasa.gov/) and [Langley
Air Force Base](http://www.langley.af.mil/1fw.shtml). Your imagination
will soar as you launch a rocket, pilot a space shuttle, come
face-to-face with the [Apollo 12 Command
Module](http://www.vasc.org/exhibits/spacecraft/apollo12.html), and a
[DC-9 passenger jet](http://www.vasc.org/exhibits/aircraft/dc9.html).
Experience a [3D IMAX](http://www.vasc.org/imax/index.html) film in the
Riverside IMAX Theater\...you have to see it to believe it! There is
always something new landing at the Virginia Air & Space Center! The
tour takes 2-3 hours.

**NAUTICUS**

Nauticus is a spectacular maritime-themed science center featuring
hands-on exhibits, interactive theaters, aquaria, digital
high-definition films, and an extensive variety of educational programs.
A gift shop and restaurant complement the experience. Tour takes 2-3
hours.

**USS WISCONSIN**

Berthed at Nauticus, the Battleship *Wisconsin* is one of the largest
and last battleships ever built by the U.S. Navy. Explore its deck
through a self-guided or audio tour that will take you back in time to
experience this majestic ship that earned five battle stars during World
War II.

# YORKTOWN

YORKTOWN, Va.---America's evolution from colonial status to nationhood
is chronicled at the Yorktown Victory Center through a unique blend of
timeline, thematic exhibits and outdoor living history that emphasizes
the experiences of ordinary men and women during the American
Revolution. The state-operated museum is an excellent starting point for
a tour of Yorktown, where the climactic military campaign of the War for
Independence took place in the fall of 1781.

Yorktown will involve walking and the tour takes 2-3 hours.

**THE VICTORY ROVER**

See the World's Largest Naval Base aboard the Victory Rover! The 2-hour
naval base cruise departs daily from the Nauticus Docks, home to the
Battleship USS Wisconsin. Enjoy a fascinating and entertaining
commentary along the way aboard this nautically themed vessel. Thrill to
the sign of aircraft carriers, nuclear submarines, guided missile
cruisers and all of the other ships that form the world's most powerful
armada. On board, guests will enjoy plenty of comfortable seating, clean
restrooms, air-conditioned enclosed deck, an open-air upper deck, snack
bar and souvenir shop.

**VIRGINIA BEACH**

Virginia Beach became a vacation spot in 1607 when Admiral Christopher
Newport organized the 30 or so men who were to go ashore. It was
springtime and as the adventurers climbed the huge sand dunes their view
of the dogwood trees in full bloom, and the climbing yellow jasmines
intermingled with the deep green recesses on the woodland moved 26 year
old Master George Percy to write that, \"Heaven and Earth never agreed
better to frame a place for man\'s habitations than Virginia.\" Shopping
at the oceanfront is an age-old tradition. Everyone who comes to
Virginia Beach ends up walking down Atlantic Avenue, stopping to shop
and buy souvenirs along the way. This will be a relaxing getaway at the
ocean front.

**VIRGINIA SPORTS HALL OF FAME**

The Hall of Fame is filled with interactive exhibits and hands-on
activities for the whole family. In this Hall we honor great champions
and celebrate the great characters of our rich sports history. Welcome
to the NEW Virginia Sports Hall of Fame! Tour takes 2 hours.

# BASS PRO SHOP

The local Bass Pro Shop has opened their doors to National Golden Age
Games participants and is arranging for Archery, Rock Climbing, and
Arcade exhibits. The activities may expand more come May 2006, but it
won't be boring! The activities could take 1-2 hours. Minimal walking is
involved.