Form 3-2571 Native Youth Climate Adaptation and Leadership Congress

FWS Form 3-2571 (Rev. 09/2023)
U.S. Department of the Interior

OMB Control No. 1018-0176
Expires ##/##/20##

NATIVE YOUTH CLIMATE ADAPTATION LEADERSHIP CONGRESS
JR. FACULTY NOMINATION FORM
U.S. Fish and Wildlife Service
National Conservation Training Center
[Insert Dates]
What:
Jr. Faculty are enrolled college-age students that serve as mentors to high school students alongside and in concert with
the high school student’s adult mentors during the Native Youth Climate Adaptation Leadership Congress (NYCALC/
Congress). During the week of Congress, several workshops for Jr. Faculty will provide additional training in leadership
skills and career development. Participation as a Jr. Faculty also opens the opportunity to join the network of Fresh Tracks
at the Aspen Institute, which provides young Indigenous, rural, and urban leaders with cross-cultural community-building
skills, leadership development training, civic engagement opportunities, and resources for innovative youth and communityled action.
How to nominate:
Each agency can nominate and sponsor 3 to 5 Junior Faculty for NYCALC, including per diem and travel
arrangements. Each Agency may submit a maximum of five Jr. Faculty nominations for NYCALC. Supervisors
must complete this form and submit it to your agency’s lead point of contact for NYCALC. If there are more than five
nominations, it is the responsibility of the lead NYCALC coordinator to determine which top five to be submitted to
NCTC.
**If you are interested in being a Jr. Faculty but do not have a nominating/supporting agency, you may still submit your
nomination form and indicate "need agency support." We will try to secure funding, but Jr. Faculty will be accepted on a
case-by-case basis, dependent on available funding.**

NOTE: Please have Jr. Faculty Nominee complete the following information, answer the questions
below (see page 2), and provide a resume to submit with the nomination form.

Nominations Due: [Insert Dates]
Submit to: NYCALC Coordinator: [email protected]

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OMB Control No. 1018-0176
Expires ##/##/20##

FWS Form 3-2571 (Rev. 09/2023)
U.S. Department of the Interior

Nominee Information: Please include a resume with this form.
First name:

Last Name:

Nominee’s Tribal Affiliation:

Nominee’s Phone Number:

Nominee’s Email Address:

Nominee’s Organization:

Nominee’s Organization Address:

Jr. Faculty Nominee: Please briefly answer the following questions:
What strengths can you bring to share with the other Jr. Faculty and the larger NYCALC
community?
How do you hope to grow by participating in NYCALC?
What would you like to learn or what opportunities are you looking for?
What change do you hope to make or impact do you hope to have in your home community?

***Must provide resume with this nomination form****

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FWS Form 3-2571 (Rev. 09/2023)
U.S. Department of the Interior

OMB Control No. 1018-0176
Expires ##/##/20##

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 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: INTERIOR/DOI-16, Learning Management
System, available at https://www.doi.gov/privacy/doi-notices.
Disclosure: Providing the requested information is voluntary. However, failure to provide the information may prevent
participation in the program.
PAPERWORK REDUCTION ACT STATEMENT
We are collecting this information subject to the Paperwork Reduction Act (44 U.S.C. 3501 et seq.) 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 information collection and assigned OMB Control Number 1018-0176.
ESTIMATED BURDEN STATEMENT
We estimate it will take 20 minutes to complete the application form, including time to read instructions and gather
information. You may submit comments on any aspect of this information collection to the Service Information Collection
Clearance Officer, U.S. Fish and Wildlife Service, 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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