Form 3-2572 Native Youth Climate Adaptation and Leadership Congress

FWS Form 3-2572 (Rev. 09/2023)
U.S. Department of the Interior

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

NATIVE YOUTH CLIMATE ADAPTATION LEADERSHIP CONGRESS
ENROLLMENT AND EMERGENCY CONTACT INFORMATION
U.S. Fish and Wildlife Service
National Conservation Training Center

Print Clearly
________________________________________ ___________________________________
Last Name, First Name, Middle Initial

Preferred Name/Nickname

________________________________________ ___________________________________

Street Address

City, State, Zip Code

________________________________________
Email

________________________________________ ___________________________________
Phone Number(s)

Cell-Phone Number

____________________________________________________________________________
Organization’s Name and Point of Contact

__________________________________ _________________________________________
Organization’s Street Address

Organization’s City, State, Zip Code

___________________________________
Organizational POC's Telephone Number

__________________________________

Organizational POC's Email

_______________________________________________________
Nearest airport to your home to coordinate travel

____________________________________ _______________________________
Person to Notify in case of an emergency

Emergency Email

____________________________________________
Emergency Phone Number

______________________________________________________________________
Additional Information We Should Be Aware Of?

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FWS Form 3-2572 (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 10 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 Info_Coll@fws.gov. Please do not send your completed form to this address.

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