Form 3-2548 Native Youth Community Adaptation and Leadership Congres

FWS Form 3-2548 (Rev. 04/2021)
U.S. Department of the Interior

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

Native Youth Community Adaptation and Leadership Congress
Student Conduct Agreement

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Print Student’s Last Name, First Name, Middle Initial

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Print Student’s Preferred Name/Nickname

In as much as the U.S Fish and Wildlife Service, National Conservation Training Center (NCTC), New Mexico
Wildlife Federation, federal agency staff, and chaperones for this trip will be assuming supervisory
responsibilities for your child at the conference, away from home and school, the student and the parents/
guardians must fully understand the rules which govern the conference. This program is a continuation of the
School or Youth Group that your child attends, and all students are subject to the same rules and regulations
that govern their behavior at their School or in their Youth Group while they are on the NCTC campus.
Because the students will be representing their Tribes, Communities, Schools, and Youth Groups, we have
established the following additional rules for the conference:

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I will conduct myself in a manner that will contribute to a sense of community among all participants and
foster an atmosphere of mutual respect.
I will follow the rules set forth in the NCTC guidelines including the dress code.
There will be no use of alcoholic beverages, drugs, tobacco or any illegal substances.
All medications will be reviewed with the Health Coordinator during check-in and must be referenced in
the Medical Release form completed by the parent or guardian.
Rooms will be assigned by NCTC and may be changed only by the chaperones.
Under no conditions at any time will students of opposite sexes be in the same room without the
presence of an authorized chaperone.
By curfew time or the time established for bed check, students are to be in their assigned rooms and will
remain there for the rest of the night.
No students will be allowed to leave the group on their own or with friends without the permission of their
assigned chaperone. This includes leaving in cars, cabs, buses, etc., other than the transportations
arranged by the chaperones.
Students will be held responsible for any loss or damage to their assigned NCTC or other hotel rooms.
Because there are other guests at the conference center, students will be respectful of the effect of their
behavior on others.
The luggage and personal effects of the students are subject to inspection prior to departing and at any
time during the conference.
Students will be expected to know and observe the time and locations of all travel departures.
The establishment and enforcement of any guidelines not covered here specifically, including guidelines
that are necessary to insure the success of the conference, will be at the discretion of the chaperones.

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I understand that any infraction of the above listed rules may result in my immediate dismissal from
the conference; that I may be sent home at my parent/guardian’s expense; and that I may be subject to
further disciplinary action consistent with local, state, and federal law. Your agreement certifies that
you have read, understood, and voluntarily consent to abide by the above rules and guidelines.
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Student Signature
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Print Parent Name

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Date

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Parent/Guardian Signature

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Date

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.

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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.