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2. Primary Applicant

4. First Name*
5. Last Name*
7. Preferred Name
9. Date of Birth*
   Date of Birth
10. Age*
11. Gender
    -- Select One --FemaleMaleNon-binary
13. Address*
15. City*
16. Province*
17. Postal Code*
19. Phone Number*
20. Cell Number
22. Email Address
24. Client ID (for Sign Me Up Recreation Registration account)

26. Additional Family Members

28. List additional family members below. One adult(s) married or common-law partner and children aged 18 and younger. Any other family members will need to apply separately.

30. First Name
31. Last Name
33. Preferred Name
35. Date of Birth
    Date of Birth
36. Age
37. Gender
    -- Select One --FemaleMaleNon-binary
41. First Name
42. Last Name
44. Preferred Name
46. Date of Birth
    Date of Birth
47. Age
48. Gender
    -- Select One --FemaleMaleNon-binary
52. First Name
53. Last Name
55. Preferred Name
57. Date of Birth
    Date of Birth
58. Age
59. Gender
    -- Select One --FemaleMaleNon-binary
63. First Name
64. Last Name
66. Preferred Name
68. Date of Birth
    Date of Birth
69. Age
70. Gender
    -- Select One --FemaleMaleNon-binary
74. First Name
75. Last Name
77. Preferred Name
79. Date of Birth
    Date of Birth
80. Age
81. Gender
    -- Select One --FemaleMaleNon-binary
85. First Name
86. Last Name
88. Preferred Name
90. Date of Birth
    Date of Birth
91. Age
92. Gender
    -- Select One --FemaleMaleNon-binary
96. First Name
97. Last Name
99. Preferred Name
101. Date of Birth
     Date of Birth
102. Age
103. Gender
     -- Select One --FemaleMaleNon-binary

105. If your application does not include agency or adjudicator verification, please move ahead to the Verification File Upload section. 

107. Agency or Adjudicator Verification

109. Is this application a referral from an agency or adjudicator?

     1. Agency
     2. Adjudicator
111. Agency and Adjudication Information Form
     Financial Assistance for Recreation

     If you require a hard copy signature on this form, please print a PDF version of this form.

113. Your signature confirms the applicant/family:

     1. Currently lives in Coquitlam
     2. Receives government/income assistance
     3. Receives Resettlement Assistance (RAP)
     4. Falls within the Low Income Cut Off (LICO) Guidelines

     I certify that the information provided is correct and complete to the best of my knowledge .

115. Organization Name
117. Title/Position
118. Referred by
120. Email
121. Phone
123. Electronic Signature Agreement

     By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

     1. I agree.
125. Electronic Signature

127. Address Verification

129. Submit  one proof of residency that can include: cable, gas, electricity, phone, internet, utility, rental agreement, bank statement, Adjudicator, Agency, ID, or other government documents.

131. Income verification

133. We require documents to verify address and income. For privacy reasons, you can:

     • Submit photocopies/scans
     • Black out or redact information that is not relevant to the FAR application. For examples, if you submit:
       • Driver’s License – Black out DL number
       • Income Statement – Black out Social Insurance (SIN) number
       • Bank Statement – Black out account number

135. Submit document(s) showing your total income before tax (gross income). Options include: 

     - Income Statement (Option C print) for each family member who contributes to the household income and expenses
     Please note: we do not accept Notice of Assessments (NOA) or T1 general forms
     
      OR

     - Main Applicant proof of government assistance

     OR

     - Main Applicant proof of receiving Compass Card (Red)

     OR

     - Completed Adjudicator or Agency signature section of application

137. Verification File #1
139. Verification File #2
141. Verification File #3
143. Electronic Signature Agreement

     By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

     1. I agree.

145. By clicking submit on this form you are consenting to the collection, storage, use and disclosure of your personal information. The City has authority to collect, use and disclosure your information for the purposes of responding to your inquiry in accordance with Section 26(c), 33.2(a) and 32(a) of the Freedom of Information and Protection of Privacy Act The information provided by you will be used solely for the purposes of the Financial Assistance for Recreation Program and will not be used for any other purpose. Your personal information will be disclosed to a third-party service provider (i.e. website host) located in Canada for the purpose of responding to your application. If you have any questions about the collection, use or disclosure of your personal information please contact the Community Services Coordinator, at 3000 Guildford Way, Coquitlam, BC V3B 7N2 or  by email.

147. Electronic Signature
Leave This Blank:


149. 1. Receive an email copy of this form.
150. Email address

     This field is not part of the form submission.

151. Submit

* indicates a required field