The Department of Veterans Affairs (VA) Application for Voluntary Service, captured through VA Form 10-7055, serves as a vital gateway for individuals seeking to contribute their efforts voluntarily within the VA system. This form not only streamlines the process of engaging volunteers but also underscores the commitment to augmenting veterans' healthcare through community participation. The form is specifically designed to assist both voluntary organizations, which recruit volunteers from their membership, and the VA itself in the meticulous selection, screening, and placement of volunteers across the nationwide VA Voluntary Service program. This initiative importantly complements the medical care and treatment afforded to veteran patients in all VA facilities. By requiring applicants to provide information such as personal details, availability, experience, and any limitations to their service, the form plays a crucial role in ensuring that volunteer placements are both satisfactory and beneficial to the overarching goals of veteran care. Furthermore, the form addresses privacy concerns, outlining how the information provided may be used and disclosed, adhering to the Privacy Act of 1974. The inclusion of a waiver for claims to monetary benefits underscores the altruistic nature of the volunteer work, emphasizing the program’s focus on service rather than compensation. Through this comprehensive approach, VA Form 10-7055 encapsulates the structured yet compassionate framework within which volunteers contribute to the lives of veterans, embodying a significant aspect of the VA’s wider volunteer recruitment and management efforts.
| Question | Answer |
|---|---|
| Form Name | Va Form 10 7055 |
| Form Length | 2 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 30 sec |
| Other names | disqualifies, 2006, solicited, disclosures |
OMB Number
Estimated Average: 15 min.
Department of Veterans Affairs APPLICATION FOR VOLUNTARY SERVICE
T he Papenvork Red uction Act of 1995 requires us to notifY you that this information collection is in accordance with the clearance requirements of section 3507 of the Paperwork Reduction Act of I 995 . We may not conduct or sponsor, and you are not required to respond to a collection of information unless it displays a valid OMB number. We anticipate that the time expended by all individuals who must complete this form will average I 5 minutes. This includes the time it will take to read instructions, gather the necessary facts and fill out the form . The form is used to ass ist personnel of both volun tary organizations, which recruit volunteers from their membership, and the VA in the selection, screening and placement of volunteers in the nationwide VA Voluntary ervice program . The volunteer program supplements the medical care and treatment of veteran patients in all VA facilities .
PR!VA Y ACT INFORMATION: The information requested on this form is solicited under the authority of38 U . .C. 513 and will be used in the selection and placement of potential volunteers in the VA Voluntary ervice Program. The information you supply may be disclosed outside VA as permitted by Jaw; possible disclosures include those described in the 'routine uses' identified in the VA system of records 57VA 125 Voluntary ervice Records- VA , published in the Federal Register in accordance with the Privacy Act of I 974. The routine uses include disclosures: in response to court subpoenas, to report apparent law violations to other Federal , State or local agencies charged with law enforcement responsibilities, to service organizations, employers and Unemployment Compensation Offices to confirm volunteer service, and to congressional offices at the request of the volunteer. Disclosure of the information is voluntary, however, failure to furnish the information will hamper our ability to arrange the most satisfactory assignment for you and the Department of Veterans Affairs.
NAME (Last, First, Middle Initial) |
ADDRESS (Street , City, State and Zip Code) |
DATE |
Date of Birth
Te lephone Number |
Email Add ress (Optional) |
ORGANIZATION MEMBERSHIP(S) Unit, Post, Chapter, if affiliated)
1 .
EXPERIENCE AND TRAINING (special skills/abilities)
RESTRICTIONS , LIMITATIONS OF SERVICE (Health concerns , medications, allergies, etc.) |
AVAILABILITY (Days and times) |
IN CASE OF EMERGENCY PLEASE CONTACT (name, relationship , phone num ber)
Monetary Waiver: I hereby waive all claims to monetary benefits for services rendered as a volunteer worker on a " without compensation basis" for an indefinite period. I understand that this waiver applies only to remuneration (compensation) for specific services rendered in the VA Voluntary ervice (VA VS) Program and is not related to any other VA services or benefits to which I may be entitled. ( OTE: VA has entered into this agreement by the authority of 38 U .S.C., ection 5 I 3. This agreement may be canceled by either party upon written notice.) I hereby accept the volunteer appointrnent(s) as outlined above.
Volunteer's Signature |
Date |
I hereby appoint this applicant as a VA
|
VA V Program Manager- Appointing Official ignature |
Date |
|
OFFICE USE ONLY |
|
1 . SUPERVISOR |
2 . SUPERVISOR PHONE NUMBER |
|
3. ORIENTATIONS |
4 . UNIFORM |
|
COMMENTS |
NAME AND TITLE OF REVIEWER |
DATE |
VA FORM |
|
|
MAR 2008 |
EXISTING STOCK OF VA FORM |
NOTE TO STUDENTS AND PARENTS : The VA med ical center is a federal building , and , as such , must be open to the public. Our employees , patients and volunteers come from diverse backgrounds . Eligible veterans are entitled to services offered by VA, even if they have had problematic incidents in their past - unless the law specifically disqualifies them. Our job is to provide veterans care and to protect our employees , patients and volunteers as that care is provided .
STUDENT VOLUNTEER: If accepted , I agree to adhere to the policies and procedures of this VA healthcare facil ity and to respect the confidentiality of information pertaining to the patients and their
treatment. If a patient, staff member, volunteer, and/or visitor is abusive , makes inappropriate gestures , advances or conversation , that is in a manner which makes me feel uncomfortable, I will immediately inform my supervisor or a VAVS staff member.
Signature___________ _________ _
Date _____ ___
PARENT/GUARDIAN: The above named student has my consent as parent/guardian to serve as a Student Volunteer in this VA healthcare system . I have read the above agreement as signed by my student and understand their obligation to the program if they are accepted into the VAVS Student Volunteer Program . I also grant permission for my ch ild to receive emergency medical treatment if injured while volunteering .
Signature_____________________
Date -
NOTE : Completion of this application does not guarantee acceptance into this program .