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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.

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Section 1: Principal Applicant

Section 2: Adjudicator

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