North Perth Sporks for Kids Fund 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): ______ Please indicate amount you are able to contribute: _____________________________ REQUEST AMOUNT $_______________ Sport Organization contact (if known): __________________________________________________________

Sport Organization Address: ___________________________________________________________________

(Max. amount $300)

City:________________________________ Province/Territory: _________________ Postal Code: ____________________________ Sport Organization E-Mail (if known) : _________________________________________ Tel: (__________)_______________________

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.

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: _________________________________________________________________________________________________________ _______________________________________________________________________________________________________________

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: __________________