PLAY PROGRAM APPLICATION FORM (for Mission residents only)
Name of Applicant: __________________________________________________________ Name of Spouse/Partner: ___________________________________________________ Address: __________________________________
Postal Code: ________________
Home Phone: __________________________
Work Phone: ________________
e-mail: __________________________________ (your e-mail address will remain confidential) Household Members
Age
Birth Date
You are eligible to participate in the PLAY Program when your combined gross household income is at or below the following income thresholds:
Statistics Canada Low Income Thresholds # in household
1
2
3
4
5
6
7 or more
Income under
18,147
22,591
27,773
33,721
38,245
43,135
48,024
PLAY Cards will be cancelled if information provided is discovered to be false. Attach most recent tax return summary supplied by Revenue Canada. It is a serious offence to provide inaccurate inVer. 07/07 formation on this form. Consent Form:
If requested, I ________________________________ agree to meet with a representative of the
District of Mission and will disclose financial information detailed on my latest Revenue Canada tax return.
Self-declaration: I, ________________________ hereby declare on ___________________ (date) that my combined household income currently is estimated per year at ___________________.
Providing Leisure All Year Who is Eligible?
Residents of the District of Mission whose combined gross household income is at or below the most recent Statistics Canada Low Income thresholds (see front of this application form).
How Do I Apply?
1.
Complete one application per household and bring to the Reception Office at the Mission Leisure Centre along with your most recent Tax Return Summary supplied by Revenue Canada.
2.
Bring proof of residency with you. In order to be issued a PLAY Card, all adults in your household must come to the Leisure Centre and provide a driver’s license or other proof of residency.
3.
PLAY Cards will be issued to each member of eligible households. PLAY Cards are good for one year from the date of issue.
Personal Information Declaration The information on this form is collected under the authority of Section 26 (c) of the Freedom of Information and Protection of Privacy Act. The information provided will be used to evaluate eligibility for participation in the District of Mission’s PLAY Program. If you have any questions about the collection and use of this information, please contact the Deputy Director of Parks, Recreation and Culture at 604-820-5350
FOR OFFICE USE: Application received:
__________ / _______ / _______
Proof of Residence shown:
Yes
Month
Day
Year
Staff Signature: _______________________________________
Yes / No
Renewal?: Expiry Date:
__________ / _______ / _______ Month
Day
Year
# of Play Passes Issued: Adult : ____________
Youth : ____________
Child : ____________
Senior : ______
Approval:__________________________________________