Form 3-2546 Native Youth Community Adaptation and Leadership Congres

OMB Control No. 1018-0176
Expires ##/##/####

FWS Form 3-2546 (Rev. 04/2021)
U.S. Department of the Interior

Native Youth Community Adaptation and Leadership Congress
Student Enrollment Information

Please note before completing this registration package that the conference will be held on June 26- July 3, 2020.
Once travel arrangements have been made, the airfare is non-refundable. Please be sure your student is 100%
sure they will attend the conference before completing these forms.
Print Clearly

Student’s Last Name, First Name, Middle Initial

City, State, Zip Code

Parent/Guardian Email

Parent/Guardian Name

Parent/Guardian Phone Number(s)

____ Male

Student’s Cell Phone Number

____ Female

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Students Age:

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Student’s Home Street Address

Student’s Gender:

Student’s Preferred Name/Nickname

High school grade just
completed:

Date of Birth: __________
Student’s Chaperone

School or Group Name (Please use exact official name)

School/Group Street Address

School Group City, State, Zip Code

School/Group Telephone Number

School/Group Email

OMB Control No. 1018-0176
Expires ##/##/####

FWS Form 3-2546 (Rev. 04/2021)
U.S. Department of the Interior

NOTICES
PRIVACY ACT STATEMENT
Authority: The information requested is authorized by the Government Organization & Employee Training Act (5 U.S.C. 4101,
et seq.), Executive Order 11348 (Providing for Further Training of Government Employees), Americans with Disabilities Act and
the E-Government Act of 2002, (42 U.S.C. 112101) and the E-government Act of 2002 (44 U.S.C. 3501).
Purpose: To enroll students for National Conservation Training Center (NCTC) hosted programs.
Routine Uses: The information on this form may be used by program leaders to contact those selected for the NYCALC
program. Information may be disclosed to the Department of Justice (DOJ), a court, adjudicative or other administrative body,
the fiscally sponsoring organization or agency of the student, a party in litigation before a court or adjudicative or administrative
body; or any DOI employee when represented by DOI or DOJ for legal proceedings or as required by law pursuant to the
routine uses identified in the System of Records Notice: DOI Learn, Interior – DOI-16.
Disclosure: Providing the requested information is voluntary. However, failure to provide the information may prevent
participation in the program.
PAPERWORK REDUCTION ACT STATEMENT

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In accordance with the Paperwork Reduction Act (44 U.S.C. 3501, et seq.), the U.S. Fish and Wildlife Service collects
information to assure the health and safety of participants while on site at the National Conservation Training Center for the
Congress. Your response is voluntary and we will not share your response publicly. We may not conduct or sponsor and you
are not required to respond to a collection of information unless it displays a currently valid OMB Control Number. OMB has
reviewed and approved this focus group and assigned OMB Control Number 1018-0176.
ESTIMATED BURDEN STATEMENT

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We estimate public reporting for this collection of information to average 30 minutes, including time for reviewing instructions,
gathering and maintaining data and completing and reviewing the form. Direct comments regarding the burden estimate or any
other aspect of the form to the Service Information Clearance Officer, Fish and Wildlife Service, U.S. Department of the Interior,
5275 Leesburg Pike, MS: PRB (JAO/3W), Falls Church, VA 22041-3803, or via email at [email protected]. Please do not
send your completed form to this address.