Appendix C: Canadian Tire Jumpstart Application Form

Canadian Tire Jumpstart Application Form

SECTION 1: APPLICATION INFORMATION

Child’s Name: ______

Birth Date (dd/mm/yy): ______/______/______Gender: ______

Address:______

City:______Province/Territory: ______Postal Code: ______

Tel: (______)______Email:______

Name of Parent/Guardian: ______

SECTION 2: REQUEST FOR FUNDING

Please identify the sport or activity for which you are requesting funding: Minor Hockey

Organization offering the sport or activity: Medicine Hat Minor Hockey Association

Start Date: September 2014End Date: March 2015 # of Sessions: N/A

Length of session (in minutes): 60-120

Explanation of Fees/Costs: Registration fees

Please indicate amount you are able to contribute: $200.00

Please indicate type of fees/costs requested from Jumpstart: Registration fees

Request: Registration remainder of ()

Organization contact: Brian VargaTel: (403 ) 527-5773E-Mail: ______

Address:Box 21021 City: Medicine Hat

Province/Territory: Alberta Postal Code: T1A 8M3

SECTION 3: ENDORSEMENT

Community Leader (School Principal/Guidance Counselor/Doctor/Dentist/Lawyer)

Name: ______Address: ______

City: ______Province: ______Telephone: (______)______

Email: ______Please indicate relationship to applicant: ______

I certify my endorsement of the above child/youth and verify that all the information given is correct and can

besubstantiated.

Signature: ______Date: ______

If possible, please attach a letter from a community leader indicating relationship to applicant verifying the applicant’s economic barrier to participate in the requestedactivity or program. The community leader should be in a position to identify and assess the economic barriers of the applicant.

Organization: ______Position: ______

Address: ______City: ______Province/Territory: ______

Tel (w): (______)______Email: ______

Canadian Tire Jumpstart and its members will respect the confidentiality of all applicants. By completing this application, I hereby authorize Canadian Tire to contact meand Canadian Tire Jumpstart Chapters to consult with the endorser and share this information with the organization or company that will receive the payment for my child. All information captured above is a requirement of Canadian Tire Jumpstart and is submitted electronically as part of the requirement for funding. All personal information issecured and protected and will not be used for any other purpose other than reference to the funding provided.

Have you used Jumpstart before? (Y / N) When? ______

What activity? ______