Skip to Main Content
Loading
Loading
Your Government
Resident Services
Business Tools
How Do I?
Facebook
Twitter
Instagram
YouTube
LinkedIn
Search
Home
Form Center
A
A
Form Center
Search Forms:
Search Forms
Select a Category
All Categories
Bylaws & Legal
City Council
Contest Prize Release Forms
Corporate Services
Customer Feedback
Economic Development
Engineering & Public Works
Environment
FAR
Filming
Fire & Rescue
Fitness
Grants
Parks, Recreation & Culture Services
Pets & Animals
Planning and Development
PRCF Camp Forms
Stakeholders
Winter Wise
By
signing in or creating an account
, some fields will auto-populate with your information and your submitted forms will be saved and accessible to you.
Adjudication Information Form
Sign in to Save Progress
This form has been modified since it was saved. Please review all fields before submitting.
Steps
1.
Section 1: Principal Applicant
This section is complete
This section is incomplete
2.
Section 2: Adjudicator
This section is complete
This section is incomplete
Section 1: Principal Applicant
First Name
Last Name
Address
City
Province
Postal Code
Date of Birth
Date of Birth
Gender
-- Select One --
Female
Male
Other
Phone Number
Email Address
Continue
Section 2: Adjudicator
First Name
Last Name
Organization
Position
Address
City
Province
Postal Code
Phone Number
Email Address
How long have you known the applicant?
Relationship to the applicant?
I have read and understand the guidelines of the Get Connected, Get Active—Financial Assistance for Recreation Program and agree that this applicant/family:
Lives in Coquitlam
Meets the financial guidelines as indicated in the Low Income Cut-Off (LICO) table
I believe the applicant/family has significant financial need and assistance from the City of Coquitlam would allow the applicant to participate in and benefit from recreation activities. I agree to participate in a brief telephone follow-up if required. I certify that the information given in this form is, to the best of my knowledge, correct and complete.
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.
I agree.
By checking "I agree" you are consenting to the voluntarily collection and use of your personal information in accordance with Section 26(d) of the Freedom of Information and Protection of Privacy Act. The information provided by you will be used solely to indicate your interest in participating in the Get Connected Get Active program. Your information will not be used for any other purpose. If you have any questions about the collection, storage, correction and | or use of your personal information please contact Karen Basi - City of Coquitlam, Parks Recreation and Culture, at 604-927-3599.
Electronic Signature
Leave This Blank:
Receive an email copy of this form.
Email address
This field is not part of the form submission.
Submit
|
Go Back
* indicates a required field
Agendas & Minutes Search
Map to City Hall
Media Centre
Careers
View current
job listings
Agendas & Minutes
Follow City Council
meetings
Online Services
Pay bills,
applications & licences
Service Requests
Questions, comments
& report a problem
Have Your Say
Contribute your ideas
and feedback
Stay Connected
Stay informed on
news & projects
Arrow Left
Arrow Right
[]
Slideshow Left Arrow
Slideshow Right Arrow