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Financial Assistance for Recreation Application Form

  1. Primary Applicant

  2. Additional Family Members

  3. 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.

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

  5. Agency or Adjudicator Verification

  6. Is this application a referral from an agency or adjudicator?
  7. Your signature confirms the applicant

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

  8. 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.

  9. Address Verification

  10. 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.

  11. Income verification

  12. 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

  13. 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.

  14. 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 Chris Cordova, Recreation Facility Supervisor, at 3000 Guildford Way, Coquitlam, BC V3B 7N2 or at ccordova@coquitlam.ca.

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  16. This field is not part of the form submission.