Fill out the below information to receive an exercise starter kit(s) and sign up for Office of Academic Engagement's (OAE) email list. 

Name

Question Title

* 1. Name

E-mail Address

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* 2. E-mail Address

Name of Institution (Full Name, No Abbreviations Please)

Question Title

* 3. Name of Institution (Full Name, No Abbreviations Please)

What is your Role at your Institution?

Question Title

* 5. What is your Role at your Institution?

Which Exercise Starter Kit(s) are you Interested in?

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* 6. Which Exercise Starter Kit(s) are you Interested in?

Would you Like to Receive Email Messages from OAE's GovDelivery Service About Events, Resources, and DHS Announcements? 

Question Title

* 7. Would you Like to Receive Email Messages from OAE's GovDelivery Service About Events, Resources, and DHS Announcements? 

DHS Privacy Notice
Office of Academic Engagement Privacy Notice
This Privacy Notice serves to inform you of why DHS is requesting the information on this form.
AUTHORITY:
DHS is authorized to collect the information requested on this form pursuant to 5 U.S.C. 301 and 44 U.S.C. 3101.
PURPOSE:
DHS is requesting this information for the purpose of contacting you after you register for an event.
ROUTINE USES:
The information requested on this form may be shared externally as a “routine use” to other agencies to assist DHS in allowing you to participate in events you have registered for. For individuals covered by the Privacy Act, a complete list of the routine uses can be found in the system of records notice associated with this form, “DHS/ALL-002 Mailing and Other Lists System.” The Department’s full list of system of records notices can be found at http://www.dhs.gov/system-records-notices-sorns.
CONSEQUENCES OF FAILURE TO PROVIDE INFORMATION:
Providing this information to is voluntary. However, failure to provide this information may result in you not being able to attend the event.

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