Sample_Fields_for_FSA_Online_Registration rev1

OMB Control Number - OMB No. 0560-0226

SAMPLE ONLINE REGISTRATION FIELDS FOR FSA-HOSTED EVENTS AND CONFERENCES

Attendee Contact Information

1. *Prefix:

2. *First Name:

Latrice

3. Middle Name or Initial:

4. *Last Name:

Hill

Latrice.hill@wdc.usda.gov

5. *Email Address:

6. Title

7. Company/Organization:

8. *Affiliation:

Home or Work Address:

9. *Country:

10. *Street Address Line One:

11. Street Address Line Two:

12. *City:

13. *State/Province:

14. *ZIP/Postal Code:

15. *Address Type:

16. *Phone:

17. Invite People to our event!

Use this section to forward this invitation to other people. Do not enter the people you plan to bring with you.

First Name Last Name Email Address

First Name Last Name Email Address

Add a short message to the invitation

6characters remaining

18. WAIVERS OF CLAIM AND RELEASE OF LIABILITY

USDA Farm Service is hosting this event. FSA accepts no responsibility for any damages or injury caused by participation in this event. CONSENT TO USE OF PHOTOGRAPHIC IMAGES — Registration and attendance at, or participation in, any FSA meeting and other activities constitutes an agreement by the registrants and participants to FSA’s use and distribution (both now and in the future) of registrants’ or participants’ image or voice in photographs, videos, electronic reproductions and audiotapes of FSA events and activities.

* I have read and agree to the terms above.

19. Do you require specific aids or services, pursuant to the AMERICANS WITH DISABILITIES ACT? (Select all that apply)

• Audio

• Mobile

• Visual

• Other 

If you are a person with a disability and desire any assistive devices, services or other accommodations to participate in this activity, please contact via phone xxxxxxx or email xxxxxxx@xxxxxxxx during business hours of 8:00 a.m. - 5:00 p.m. to discuss accommodations a minimum of 30 days prior to the event.

20. What is your gender?

21. Are you a Veteran?

OPTIONAL:

Please answer BOTH questions 20 and question 21 about ethnicity and race. For this questionnaire, Hispanic or Latino origins are not races.

22. What is your Ethnicity?

23. What is your race? Mark all that apply.

• ☐American Indian or Alaska Native

• ☐Asian

• Black or African American

• ☐Native Hawaiian or Pacific Islander

• ☐White/Caucasian

• ☐Other   

24. How did you hear about the event?

• Word of Mouth

• Email

• Social Media

• Publication

• At Another Event

• Other, please specify: 

25. CHOOSE A REGISTRATION OPTION:

Select one of the options below. Registration fee does not include hotel accommodations during the conference. You will have the opportunity to reserve your hotel accommodations once you have completed your conference registration payment.

Conference Only $10.00

Includes: (Tuesday) Pre-Conference Short Course (Wednesday), Conference Sessions, Educational Tours (Dinner on your own); (Thursday) Conference Sessions.

Conference and Field Day $25.00

Includes: (Tuesday) Farm to Fork Field Day (Wednesday) Conference Sessions, Regional Tours (Dinner on your own); (Thursday) Conference Sessions

26. Submit Payment

Payment Instructions and Refund/Cancellation Policy:

You may pay by credit card or check.

CHECKS must be postmarked by xxxxx, and made payable to “xxxxxx.” 

Mail to: xxxxxxxxx

•   Credit Card - Enter your information in the section below.

• Check

NEED TO CANCEL? We look forward to seeing you at the xxxxxxxx, but should you need to cancel your registration before xxxx, please be aware there is a 25% cancellation fee. After xxxx, we regret we can no longer offer refunds.

Public Burden Statement: According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0560-0226. The time required to complete this information collection is estimated to average 15 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.

SUBMIT

QUESTIONS?  For questions regarding payment and cancellations please contact Shayla Watson at 202-690-2350.