HomeMy Public PortalAboutPRO Kids ApplicationPRO Kids APPLICATION FORM
APPLICANT INFORMATION (Please print clearly)
First Name of Child Last Name of Child
Gender:Male Female Age Birth Date
First Name of Parent or Guardian Last Name of Parent or Guardian
Civic /Mailing Address
Phone (home, work, cell)Email Address
SEASON APPLYING FOR:
WINTER SPRING SUMMER FALL
Will this child be registered in another paid
activity at the same time as this request?
Yes No
If Yes, please name activity:
ACTIVITY INFORMATION
Name of Activity:Registration Cost: $Amount Requested
from PRO Kids:$
Organization Offering Activity:Do you require help with Equipment
costs?Yes No
If so, what equipment & cost?
Organization Contact Name:Phone Number:
Activity Dates (Start and End):How many weeks?How many days per week?How long each day?
REFERENCE -Please provide the name of a reference that is familiar with your personal and financial situation and who can verify that you require
financial assistance from PRO Kids. This person should be an adult who knows the family (not a relative or close friend).
(Examples of Reference: Social Worker, Clergy, Group Leader, Coach, Teacher, Doctor)
Name of Reference Organization
Phone Numbers (home, work, cell)Email Address
Parental Consent -I authorize the above reference to release relevant personal information as required by PRO Kids. I further authorize PRO Kids
to collect this information for administration purposes including release to program providers and Canadian Tire Jumpstart.
If you prefer, you can provide us with a copy of your Notice of Assessment instead of listing a reference.
Do you give permission for Jumpstart to communicate directly with you?Yes No
Parent /Guardian Signature Date
Please Note: This application is confidential and will be used solely for the PRO Kids and Jumpstart purposes.
Municipality of Chester PRO Kids ~ Please allow up to 3 weeks for processing.~
ATTN: Cosette Howlett, PRO Kids Coordinator
151 King Street, PO Box 369,Chester NS B0J 1J0 Online Form:www.chester.ca/prokids
prokids@chester.ca Fax: 902-275-3630 Phone: 902-275-3490