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Address

How long have you known the applicant?*

Relationship to the applicant?*

I have read and understand the guidelines of the 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 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.

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