NORTH PERTH SPORTS FOR KIDS FUND/JUMP START APPLICATION Need financial assistance for your child to participate in sport and recreation programs in North Perth? Complete an application online at www.jumpstart.ca or fill out this application and contact our community partner, Listowel Salvation Army 519-291-2900, to discuss.
APPLICATION FORM: PLEASE ENSURE ALL INFORMATION IS COMPLETE AND ACCURATE (Please print clearly) SECTION 1: APPLICANT INFORMATION Child’s Name (First, Last):_______________________________________________ Birth Date (dd/mm/yyyy):_______/_______/_______ Gender:____________________ Postal Code________________
Canadian Tire Jumpstart Can Contact Family:
YES NO
Name of Parent/Guardian: ___________________________________________________________________ Address: ________________________________________________ City:______________________ Province/Territory: ____________ Tel: (_________)__________________________Email:_______________________________________________________ SECTION 2: ORGANIZATION INFORMATION & REQUEST FOR FUNDING Please identify the sport or activity for which you are requesting funding: __________________________________________________ Sport Organization offering the sport or activity (full name)__________________________________________________________________ Start Date: __________________ End Date: ___________________ # of sessions per wk: _____ Length of session (in minutes): ______ REQUEST AMOUNT $_______________ (Max. amount $300) Sport Organization contact (if known): __________________________________________________________
Please indicate amount you are able to contribute: _____________________________
Sport Organization Address: ___________________________________________________________________ City:________________________________ Province/Territory: _________________ Postal Code: ____________________________ Sport Organization E-Mail (if known) : _________________________________________ Tel: (__________)_______________________ FOR OFFICE USE ONLY Application Received (dd/mm/yy) ______ /______/______
Approved: (Y/N )______
First Time Funding: (Y/N)______ Approved Amount:$___________ Allocation Period: Spring/Summer OR Fall/Winter Notes: _________________________________________________________________________________________________________ _______________________________________________________________________________________________________________ Canadian Tire Jumpstart, North Perth Sports for Kids fund and its members will respect the confidentiality of all applicants. By completing this application, I hereby authorize Canadian Tire Jumpstart Chapters, North Perth Sports for Kids fund and its community partner, Listowel Salvation Army, to consult with the endorser and share this information with the organization or company that will receive the payment for my child. All information captured above is a requirement of Canadian Tire Jumpstart and North Perth Sports for Kids Fund and is submitted electronically as part of the requirement for funding. All personal information is secured and protected and will not be used for any other purpose than reference to the funding provided.
I verify that the information contained in this application is complete and true. I understand that I may be required to provide proof of family income. Parent/Guardian Signature:_________________________________________
Date: __________________
14 www.northperth.ca | 2021 Spring & Summer Guide | NPSFK Fund & Jump Start Application
