Form 3-2547 Native Youth Climate Adaptation and Leadership Congress

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

FWS Form 3-2547 (Rev. 06/2023)
U.S. Department of the Interior

NATIVE YOUTH CLIMATE ADAPTATION LEADERSHIP CONGRESS
PARENTAL CONSENT FORM
U.S. Fish and Wildlife Service
National Conservation Training Center
This form will serve as permission for your child to participate in the Native Youth Adaptation 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 nycalc@nmwildlife.org

Name of Student:

Birth Date:

Address:
City/State:

Zip Code:

School:

Grade:

Student’s Phone Number:
Physician’s Name:
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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FWS Form 3-2547 (Rev. 06/2023)
U.S. Department of the Interior

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

In connection with and consideration of my child’s (named above) participation in the NATIVE
YOUTH COMMUNITY ADAPTATION 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:
•
•

•

•

•

•

I understand that my child will be a participant in the Native Youth Community Adaptation
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 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 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 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
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 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 Leadership Congress and affiliated activities. In consideration of child’s
participation in the Native Youth Community Adaptation 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
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OMB Control No. 1018-0176
Expires ##/##/20##

FWS Form 3-2547 (Rev. 06/2023)
U.S. Department of the Interior

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 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
• 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.

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

FWS Form 3-2547 (Rev. 06/2023)
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 EGovernment 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
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 information
collection and assigned OMB Control Number 1018-0176.
ESTIMATED BURDEN STATEMENT
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 Info_Coll@fws.gov. Please do not send your completed form to this
address.

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