Form 3-2547 Native Youth Community Adaptation and Leadership Congres

FWS Form 3-2547 (Rev. 04/2021)
U.S. Department of the Interior

OMB Control No. 1018-0176
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NATIVE YOUTH COMMUNITY ADAPTATION AND LEADERSHIP CONGRESS
PARENTAL CONSENT FORM

This form will serve as permission for your child to participate in the Native Youth Adaptation and Leadership Congress to be
held at the National Conservation Training Center in Shepherdstown, West Virginia from [insert dates] (including travel dates).
Please carefully read and sign this parental consent form. If you have any questions or would like further information please call
the New Mexico Wildlife Federation at (505) 299-5404 or email [email protected]

Name of Student:

Birth Date:

Address:
Zip Code:

School:

Grade:

Student’s Phone Number:
Physician’s Name:

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City/State:

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Physician’s Telephone Number:
Physician’s Address:

PERSON TO BE NOTIFIED IN CASE OF EMERGENCY

Contact #1
Name: ________________________________
Relationship to Student: _____________________________
Phone: (H)________________________ (W)_________________________
Contact #2
Name: ________________________________
Relationship to Student: _____________________________
Phone: (H)_______________________ (W)__________________________

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OMB Control No. 1018-0176
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FWS Form 3-2547 (Rev. 04/2021)
U.S. Department of the Interior

In connection with and consideration of my child’s (named above) participation in the NATIVE YOUTH
COMMUNITY ADAPTATION AND LEADERSHIP CONGRESS and related activities, I, on behalf of my child
and myself, my heir(s), personal representative(s), and assign(s), hereby represent and agree to the
following:

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I understand that my child will be a participant in the Native Youth Community Adaptation and
Leadership Congress, and I hereby give my permission for him/her to serve in that capacity.
I understand that my child will be provided with the orientation and training necessary, and as
needed, for the safe and responsible performance of assigned duties. He/she will be expected
to meet all the requirements of the position including regular attendance and adherence to
New Mexico Wildlife Federation AND Native Youth Community Adaptation and Leadership
Congress policies and procedures.
Should my child require emergency medical treatment, first aid, or transportation to a hospital
or medical facility as a result of illness or injury associated with my child’s participation in the
Native Youth Community Adaptation and Leadership Congress, I consent to any such
treatment, first aid, and/or transportation that may be provided to my child, and understand
that New Mexico Wildlife Federation will not be responsible for any costs associated with any
of the foregoing.
I understand that as a participant in this program and related activities, my child may
participate in physical activity. I represent and warrant that my child is in good physical
condition, and has no physical, health related or other problems which would preclude or
restrict his/her participation in this program or related activities or otherwise render his/her
participation dangerous or harmful to him/her or others, and that he/she is allowed to
participate in physical activity.
I understand that as a participant in the Native Youth Community Adaptation and Leadership
Congress and related activities, my child will be provided with food and it is the responsibility of
my child to ask about ingredients in all food he/she chooses to ingest, and I have discussed this
responsibility with him/her.
I, the undersigned, certify that I am the parent or legal guardian of the child named above and
that I have the right to make decisions for my child that effect his/her well-being. I recognize
and acknowledge that physical injury, accident, illness, death, loss of personal property, or other
contingencies may befall my child as a participant in the Native Youth Community Adaptation
and Leadership Congress, a New Mexico Wildlife Federation affiliated program, and its related
activities. I understand that my child is not in any way required to participate in the program
and related activities, and despite these risks, I want him/her to participate in the Native Youth
Community Adaptation and Leadership Congress. In light of the preceding and with sufficient
knowledge of my child’s physical and other conditions and limitations, if any, I voluntarily
assume all responsibility and risk of loss, damage, illness and/or injury to person or property
which my child may, in any way, sustain in connection with his/her participation in the Native
Youth Community Adaptation and Leadership Congress and affiliated activities. In consideration
of child’s participation in the Native Youth Community Adaptation and

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FWS Form 3-2547 (Rev. 04/2021)
U.S. Department of the Interior

Leadership Congress and related activities, I agree to release the New Mexico Wildlife
Federation, its officers, employees, agents, and volunteers from any and all liabilities, damages,
losses and/or causes of action (collectively “Claims”) that I or my child may suffer or have,
including without limitation, to our persons or property or both, which arise out of, are related
to or in connection with, or occurring during, my child’s participation in or attendance at the
Native Youth Community Adaptation and Leadership Congress and related activities except to
the extent that any such Claims are caused by the gross negligence or willful misconduct of the
employees of the New Mexico Wildlife Federation. I further agree to indemnify and hold
harmless the New Mexico Wildlife Federation and its officers, employees, and volunteers from
any and all Claims arising out of, related to, or in connection with the Native Youth Community
Adaptation and Leadership Congress and related activities that are caused by my or my child’s
negligent or intentionally tortuous acts and/or omissions.
The following agencies will be given permission to use attendees name, likeness, image, voice,
and/or sound: Bureau of Indian Affairs, Bureau of Reclamation, Bureau of Land Management,
Environmental Protection Agency, Federal Emergency Management Administration, National
Aeronautics and Space Administration, National Oceanic and Atmospheric Administration,
National Park Service, South Central Climate Science Center, U.S. Department of Agriculture,
U.S. Forest Service, New Mexico Wildlife Federation and U.S. Geological Survey

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I agree that this agreement shall be governed by the laws of the State of New Mexico with
giving any choice or conflict of laws principles of any jurisdiction, and if any portion of this
agreement is held invalid, the remainder of the agreement shall continue in full force and effect.

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I CERTIFY THAT I AM 18 YEARS OF AGE OR OLDER AND THAT I HAVE READ, FULLY UNDERSTAND
AND AGREE TO THE TERMS OF THIS AGREEMENT, AND I SIGN IT VOLUNTARILY WITH FULL
KNOWLEDGE OF ITS SIGNIFICANCE.
PARENT/GUARDIAN NAME [PRINT]

PARENT/GUARDIAN TELEPHONE NO.
SIGNATURE

DATE

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FWS Form 3-2547 (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.

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PAPERWORK REDUCTION ACT STATEMENT
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 12 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.

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