Get Connected, Get Active...Coquitlam residents and families have the opportunity to reach their...

Please ensure the following information is included with your application:

1. Applicant Form:

If receiving Government/Income Assistance (GIS, SAFER, RAP, EI, MSDPR/MEIA, PWD), complete:

» Form 1 only—Financial Assistance for Recreation Application Form

Provide a copy of one of the following:

• Eligibility letter

• Photocopy Notice of Deposit (from Ministry of Social Development Office)

• Confirmation of Assistance Statement (myselfserve.gov.bc.ca)

• Validated Release of Personal Information (from Ministry of Social Development Office)

If NOT receiving Government/Income Assistance, complete:

» Form 1—Financial Assistance for Recreation Application Form

AND

» Form 2—Adjudication Information Form

» An adjudicator can be one of the following:A professional in social work or family services, financial case worker, a school principal, counsellor, teacher, daycare provider, church clergy/pastor, accountant, family physician, dentist

2. Government Issue Photo ID:

» Scan or copy one of the following: Driver’s license, BC Services card, BC ID, Passport, Permanent Resident card—must be current for primary applicant

3. Address verification:

» Submit two building related bills showing your current address (dated within two months of application):

• Copies of home utility bill (Hydro, gas, internet, cable, landline or cell phone) or Lease Agreement/Residential Tenancy Agreement (PO boxes not accepted).

» If Adjudicator checks “lives in Coquitlam” box, only one more proof of residency is needed from the list.

4. Return Application Package:

» Mail: Get Connected, Get Active—Financial Assistance for Recreation, 3000 Guildford Way, Coquitlam, BC V3B 7N2

» Fax: 604-927-4395

» Email: [email protected]

» In Person: at one of our recreation facilities: (Attn: Get Connected, Get Active) » Poirier Sport & Leisure Complex—633 Poirier Street, Coquitlam, BC V3J 6A9

» Dogwood Pavilion—1655 Winslow Avenue, Coquitlam, BC V3J 0E7

» City Centre Aquatic Complex—1210 Pinetree Way, Coquitlam, BC V3B 7T8

» Glen Pine Pavilion—1200 Glen Pine Court, Coquitlam, BC V3B 2P7

» Pinetree Community Centre—1260 Pinetree Way, Coquitlam, BC V3B 7Z4

NOTE: Incomplete applications will be returned to the applicant. Applicants will be informed by mail within 3 – 4 weeks.

» For more information please email [email protected] or call 604-927-6076. Leave your name and phone number and you will receive a response within 2 – 3 business days.

5. Next steps:

» A letter detailing outcome, next steps, and payment information (if applicable) will be sent directly to applicant by mail.

Get Connected, Get ActiveFinancial Assistance for

Recreation Application Package 604-927-6076 | 604-927-4395

[email protected]

Primary Applicant: (First) ________________________________________ (Last) ______________________________

Address: ____________________________________________________ , Coquitlam, B.C. Postal Code: __________

Phone: ______________________ Cell: __________________________ Client ID: (if known) _________________

Email address: __________________________________________________________________________________

List principal applicant and family members below. One or two adult(s) married or common-law partners & their legal dependants aged 18 & younger

Applicants can choose from Option A OR Option B (not both columns)

Name Birthdate (DD/MM/YYYY)

Age M/F/Other

Option A (Choose 1 of the 3 options)

Option B (Choose ONE PASS & 1 option)

First:

Last:

50 free drop-in admissions OR 2 free programs per year OR 4 half price programs per year

$10 ONE PASS year-long membership with unlimited drop-in admissions

PLUS 2 free programs per year OR 4 half price programs per year

First:

Last:




First:

Last:




First:

Last:




First:

Last:




First:

Last:




Signature of Primary Applicant: ___________________________________ Date of Application: ____________________

Find available drop-in programs at coquitlam.ca/drop-ins

Office use only

New Renewal Income Assistance verified: LICO, MSDPR, MEIA, RAP, GIS, EI, SAFER Adjudicator ____________________________________ Government Issue Photo ID: DL, BCID, Passport, PR card, BC SERV card Proof of residency: cable, gas, electricity, phone, internet, Utility, Rental agreement, NOD, Bank Statement or Adjudicator, other ____________________________________

Not Approved

Missing documentation (ID / 1 or 2 Bills / Income Verification)

Not a resident of Coquitlam

Date:___________________________________________

Form 1

Financial Assistance for Recreation Application Form

Get Connected, Get Active 604-927-6076 | 604-927-4395

[email protected]

Authorization to Release Personal Information to the Canadian Tire JumpStart Program

Background Information

The Canadian Tire JumpStart Program assists children aged 4 – 18 years to get active in sports and recreational activities.

In order for the City to access funding for this program it is necessary to release certain following information: first and last name, birthdate, gender, and postal code to the Canadian Tire JumpStart Program. The City is authorized to disclose personal information with your consent in accordance with the Freedom of Information and Protection of Privacy Act. If you do not wish your child’s information to be disclosed to the Canadian Tire JumpStart Program, please indicate this below. Refusal to provide your personal information does not impact your eligibility to receive assistance. The data is used for auditing purposes only.

Personal Information to be released to the JumpStart Program

The following personal information is required by the Program: » First Name

» Last Name

» Age/Date of birth

» Gender

» Activity Category

» Postal Code

Any other identifying information will not be included. The data is used for auditing purposes only.

Please choose one of the following options:

Yes, I am willing to have my child’s personal information included in the funding submission to the Canadian Tire JumpStart Program to assist with offsetting program costs for the City of Coquitlam’s Get Connected, Get Active—Financial Assistance for Recreation.

No, please do not disclose my personal information to the Canadian Tire JumpStart Program.

Signature of Applicant: ___________________________________________ Date: ____________________________

Contact Information

QUESTIONS?Contact us for more information, or if you have questions about your application.

City of Coquitlam Get Connected, Get ActiveFINANCIAL ASSISTANCE FOR RECREATION

3000 Guildford Way, Coquitlam BC V3B 7N2

604-927-6076 | 604-927-4395 [email protected]

coquitlam.ca/recaccess

Adjudication Process

All sections must be completed before it is returned for processing. The applicant must complete Section 1 and the approved adjudicator must complete Section 2 (as per the guidelines) and then submit to the City of Coquitlam by either mail, fax, email, scan or in person.

Section 1: Principal Applicant

Name of Applicant: (First) _____________________________________ (Last) __________________________________

Address: __________________________________________________, Coquitlam, B.C. Postal Code: _______________

Phone: _____________________ Cell: _________________________ Client ID (if known): _______________________

Date of Birth: (DD|MM|YYYY) _____| ______ | ______ Male Female Other

Email: ___________________________________________________________________________________________

Signature of Applicant: ______________________________________ Date: __________________________________

Section 2: Adjudicator (please print)

First Name: ___________________________________ Last Name: _________________________________________

Organization: __________________________________ Position: ___________________________________________

Address: __________________________________________________________________________________________

City: ________________________________________ Postal Code: ________________________________________

Phone: _______________________________________ Email: _____________________________________________

How long have you known the applicant? ____________ Relationship to the applicant? ___________________________

I have read and understand the guidelines of the Get Connected, Get Active—Financial Assistance for Recreation Program and agree that this applicant/family:

Lives in Coquitlam

Meets the financial guidelines as indicated in the Low Income Cut-Off (LICO) table (page 2)

I believe the applicant/family has significant financial need and assistance from the City of Coquitlam would allow the applicant to participate in and benefit from recreation activities. I agree to participate in a brief telephone follow-up if required. I certify that the information given in this form is, to the best of my knowledge, correct and complete.

Signature of Adjudicator: _____________________________________________ Date: __________________________

Form 2

Adjudication Information Form

Get Connected, Get Active 604-927-6076 | 604-927-4395

[email protected]

Adjudication Process

Get Connected, Get Active—Financial Assistance for Recreation Program is the City of Coquitlam’s response to addressing the barriers to participation to support Sport, Culture and Recreation and to assist residents in learning more about the community and how they can be actively involved. Coquitlam residents and families have the opportunity to reach their highest potential when they feel connected to their community and have access to physical activity, which can positively impact physical health, development of social skills, self-esteem and friendships.

Coquitlam residents who are not eligible to receive government or income assistance and still face significant financial hardship, may apply for assistance to access leisure opportunities by completing this form in conjunction with a third-party adjudicator.

Low Income Cut-Offs (LICO)—Statistics Canada Size of family unit Total gross income

1 person $5,000 – $24,949

2 persons $5,000 – $31,061

3 persons $5,000 – $38,185

4 persons $5,000 – $46,362

5 persons $5,000 – $52,583

6 persons $5,000 – $59,304

7 persons $5,000 – $66,027

7+ persons, for each additional person, add $6,723

Family: One or two adult(s) married or common-law partners and their legal dependants aged 18 and younger

Source: Statistics Canada low income figures (for 2016 tax year)

Adjudicator please read carefully

» The adjudicator must be familiar with the applicant’s financial situation (see table above) as their signature verifies the financial need of the family or applicant. An approved adjudicator is a:

• Professional in social work or family services

• Financial case worker

• School principal or teacher

• Day Care provider

• Counsellor

• Church clergy/pastor/minister, etc.

• Accountant (stamp required/business card or letterhead)

• Family doctor or dentist—if aware of financial situation (doctor/dentist stamp is required).

» The application form will be returned to the applicant if any adjudicator other than those listed above are used.

Guidelines

» Applicants must be Coquitlam residents.

» It is the responsibility of the applicant to ensure the application is complete and to forward it to the Get Connected, Get Active—Financial Assistance for Recreation Program. Incomplete applications will be returned to the applicant.

» This form needs to be completed along with Form 1.

Get Connected, Get Active...Coquitlam residents and families have the opportunity to reach their...

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