Ucluelet Parks & Recreation - SUBSIDY PROGRAM
Application Form For Residents of Ucluelet Participant Information Family Name: _______________________________ Age Category: Child (0-12 yrs) Mailing Address: _______________________________ Youth (13-18 yrs) Adult (19+ yrs) _______________________________ Senior (65+ yrs) Email Address: _______________________________ Phone: home ______________________ cell _______________________ Would you be able to particpate in the program listed below without subsidy? Would you be able to afford half of the program fee?
Y
N
N
Would you be interested in volunteering opportunities within the department?
Y
Y
N
(please note volunteering is not contingent on the application but is always appreciated)
Programs/Pass Request •
Up to a maximum of $100/person/season ie. Fall
•
Funds will be distributed based on availability
Participant's Name Program Name/Pass* Date Last First
GL (office use only)
* Please note: Universal Yoga Punch Passes are available
I, the undersigned, certify that all the information contained in this application is correct to the best of my knowledge. I am aware that the application will be considered by the Ucluelet Parks & Recreation Department and that all information contained in this application will be kept confidential.
________________________________
______________________
P.O. Box 999 - 500 Matterson Drive, Ucluelet, B.C. V0R 3A0
Signature Date Please return completed and signed form to: Ucluelet Parks & Recreation Department
For more information please contact Abby Fortune, Director of Parks & Recreation 250-726-7772 or afortune@ucluelet.ca
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