PRO Kids Application form - Municipality of the District of Lunenburg

Participant Details

First Name of Child:(*)

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Last Name of Child:(*)

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Birth Date:(*)

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Age:(*)

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Street Address:(*)

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Community:(*)

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Postal Code:

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MODL is working to identify barriers to full economic and social inclusion. Data gathered from the questions below will be used to analyze the effectiveness of PRO Kids among diverse populations.

You do not have to answer the following questions:

Do they identify as belonging to a visible minority group?(*)

YesNoPrefer not to answer Invalid Input

Do they identify as belonging to the 2SLGBTQIA+ community?(*)

YesNoPrefer not to answer Invalid Input

Do they identify as a person with a disability?(*)

YesNoPrefer not to answer Invalid Input

Applicant Details

Full Name of Parent or Guardian:(*)

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Phone (home, work, cell):(*)

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Email Address: (*)

Please let us know your email address.

Activity Details

Name of Activity:(*)

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Organization Offering Activity:(*)

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Organization Contact Name:

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Organization Phone Number:

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Registration Cost: $(*)

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Amount Requested: $(*)

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Equipment / Clothing Wanted:

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Equipment / Clothing Cost: $

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Amount Requested: $

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Details:

Will this child be registered for another paid activity at the same time?(*)

Yes

No

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If Yes, please name activity:

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Activity Dates (Start and End):(*)

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How many weeks?(*)

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How many days per week?(*)

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How long each day?(*)

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Reference or NOA

Are you providing a reference?(*)

YesNo Invalid Input

You must provide either a Reference* or your most recent Notice of Assessment.

A reference is familiar with your personal and financial situation and can verify that you require financial assistance from Pro Kids. This person should not be a relative or friend, but someone who knows your family situation. Example: Social Worker, Clergy, Group Leader, Coach, Teacher, Doctor.

Are you providing the latest Notice of Assessment?(*)

YesNo Invalid Input

Please provide a reference or most notice of assessment

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Name of Reference:

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Reference Profession / Organization:

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Reference Phone Number(s)

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Reference email address:

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Signature of Parent or Guardian:(*)

Sign Above

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Date:

July 2, 2024

Security check(*)

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