0524-NEW National 4-H Conference Registration Form

OMB Number 0524-XXXX

Expiration Date XX/XX/XXXX

NATIONAL 4-H CONFERENCE REGISTRATION FORM This form includes the information collected on the National 4-H Conference online registration system.
PARTICIPANT INFORMATION (Required) List the following information found on your photo identification.
FULL NAME (First, Last)		DATE OF BIRTH (Month Day Year)
MAILING ADDRESS		Apt, Unit, etc.
CITY		STATE		ZIP CODE
EMAIL ADDRESS		CELL PHONE NUMBER
REGISTRATION TYPE (Select one) ☐ Adult Chaperone ☐ Collegiate Facilitator ☐ USDA-NIFA Staff ☐ Collegiate Facilitator Adult Advisor ☐ Youth Leadership Team ☐ Military Connected Adult Chaperone ☐ Youth Leadership Team Adult Advisor ☐ Military Connected Youth Participant (Delegate) ☐ Youth Participant (Delegate)
T-SHIRT SIZE ☐ Small ☐ Medium ☐ Large ☐ XL ☐ 2XL ☐ 3XL
DEMOGRAPHIC INFORMATION (Optional) This information will inform our understanding of diversity and inclusion among the participants of National 4-H Conference.
AGE (on 1st day of National 4-H Conference) Youth delegates must be 15 to 19 years-old.		GRADE LEVEL
ETHNICITY (Select one) ☐ Hispanic or Latino ☐ Not Hispanic or Latino ☐ I prefer not to share		RACE (Select one or more) ☐ American Indian or Alaskan Native ☐ Asian ☐ Black or African American ☐ Native Hawaiian or Other Pacific Islander ☐ White ☐ I prefer not to share		GENDER ☐ Female ☐ Male ☐ Non-binary ☐ I prefer not to share
LODGING INFORMATION (Required) This information must be assigned by the Land-grant Institution or Military Service Branch.
CHECK-IN DATE		CHECK-OUT DATE
NAME OF ROOMMATE
REASONABLE ACCOMMODATIONS
ACCOMMODATION REQUESTED (be as specific as possible, if accommodation is time sensitive, please explain)
REASON FOR REQUEST
DIETARY INFORMATION
DIETARY RESTRICTIONS (check all boxes that apply) ☐ None ☐ Dairy Free ☐ Vegan ☐ Nut Free ☐ Gluten Free ☐ Vegetarian ☐ Other________
NAME BADGE INFORMATION
List your first name as you would like it to appear on your name badge.
List the Land-grant Institution or Military Service Branch you are representing. Examples: Purdue University, Indiana; Virginia State University, Virginia; Hill Air Force Base, Utah; USAG Brussels Army Base, Belgium
☐CTIVITY PREFERENCES
List your top three choices for challenge question topics. Challenge question topics can be found in the Delegate Handbook. (For Youth Delegates Only) 1st choice 2nd choice 3rd choice
List your delegates top three choices for community service. Community Service choices can be found in the Delegate Handbook. (For Chaperones Only) 1st choice 2nd choice 3rd choice
How many people (adult chaperones and youth delegates) are in your delegation? (For Chaperones Only)
QUESTION FOR THE U.S. SECRETARY OF AGRICULTURE (Optional)
If you had the chance to ask the U.S. Secretary of Agriculture a question, what would it be?
PARTICIPANT AFFIRMATION
☐ By checking the box to the left, I understand my behavior affects the entire National 4-H Conference community and that I represent myself, my local and state/territory 4-H Program and the 4-H Youth Development Program. Therefore, I have read, understand, and will abide by the National 4-H Conference Handbook and Code of Conduct. ☐ By checking the box to the left, I consent to the reproduction, and use, royalty-free, of motion picture films, videotapes, recorded sounds, and still photographs of me by the Communications Staff, National Institute of Food and Agriculture, United States Department of Agriculture for all purposes including, but not limited to, education, training, trade, display, editorial, advertising, promotion, art, and exhibits. In giving this consent, I release the United States, its officers, employees, nominees, and designees from liability for any violation of any personal or proprietary right I may have in connection with such reproduction, and use. ☐ By checking the box to the left, I understand that all publications, films, slides, videos, artistic or similar endeavors, resulting from my National 4-H Conference experience will become the property of the United States, and as such, will be in the public domain and not subject to copyright laws. ☐ By checking the box to the left, I consent to receive email, mail, texts, or phone call communications relating to announcements, assignments, logistics, mentoring, or similar matters regarding the National 4-H Conference. ☐ By checking the box to the left, I consent to participate in National 4-H Conference evaluation by a third-party evaluator. Evaluation may include participating in observations, evaluations, and feedback relating to a participation in National 4-H Conference activities (such as survey assessments or formal observations). I consent to share my demographic information (such as age, ethnicity, race, gender identity, Land-grant University, etc.) with the third party National 4-H Conference evaluator. ☐ By checking the box to the left, I consent to be transported while participating in and traveling to and from this event by hired drivers authorized by the organizers of National 4-H Conference.
PARTICIPANT NAME (First, Last)	PARTICIPANT SIGNATURE		DATE
PARENT/GUARDIAN CONSENT
☐ By checking the box to the left, I affirm that I am the parent/guardian of the above-named participant and consent to their participation in National 4-H Conference. I have read, understand, and agree to follow the National 4-H Conference Handbook and provide consent for the participant affirmation(s) checked above. I understand that providing consent is voluntary and not required. I understand that not providing consent may limit this young person’s ability to participate in National 4-H Conference.
PARENT/GUARDIAN NAME
EMAIL		TELEPHONE NUMBER
PARENT/GUARDIAN SIGNATURE		DATE
NON-DISCRIMINATION STATEMENT
In accordance with federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its Agencies, offices, and employees, and institutions participating in or administering USDA programs are prohibited from discriminating based on race, color, national origin, religion, sex, gender identity (including gender expression), sexual orientation, disability, age, marital status, family/parental status, income derived from a public assistance program, political beliefs, or reprisal or retaliation for prior civil rights activity, in any program or activity conducted or funded by USDA (not all bases apply to all programs). Remedies and complaint filing deadlines vary by program or incident. Persons with disabilities who require alternative means of communication for program information (e.g., Braille, large print, audiotape, American Sign Language, etc.) should contact the responsible Agency or USDA’s TARGET Center at (202) 720-2600 (voice and TTY) or contact USDA through the Federal Relay Service at (800) 877-8339. Additionally, program information may be made available in languages other than English. To file a program discrimination complaint, complete the USDA Program Discrimination Complaint Form, AD-3027, found online at http://www.ascr.usda.gov/complaint_filing_cust.html and at any USDA office or write a letter addressed to USDA and provide in the letter all of the information requested in the form. To request a copy of the complaint form, call (866) 632-9992. Submit your completed form or letter to USDA by: (1) mail: U.S. Department of Agriculture Office of the Assistant Secretary for Civil Rights 1400 Independence Avenue, SW Washington, D.C. 20250-9410; (2) fax: (202) 690-7442; or (3) email: program.intake@usda.gov. USDA is an equal opportunity provider, employer, and lender. Public reporting for collection of information is estimated to average 1 hour, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information, unless it displays a current valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to NIFA, OGFM, 2312 East Bannister Road, Mail Stop 10,000, Kansas City, MO 64131, Attention Policy Section. Do not return the completed form to this address. National Institute of Food and Agriculture US Department of Agriculture OMB No. 0524-NEW Form Approved For Use Through xx/xx/xxxx

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USDA is an equal opportunity provider, employer, and lender.