PRO Fund Application form - Municipality of the District of Lunenburg

Participant Details

First Name:(*)

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Last Name:(*)

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Phone Numbers(s):(*)

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Email Address: (*)

Please let us know your email address.

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 Fund among diverse populations.

You do not have to answer the following questions:

Do you identify as belonging to a visible minority group?

YesNoPrefer not to answer Invalid Input

Do you identify as belonging to the 2SLGBTQIA+ community?

YesNoPrefer not to answer Invalid Input

Do you identify as a person with a disability?

YesNoPrefer not to answer Invalid Input

Applicant Details

Name of Applicant (if different from above):

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Phone Number (Applicant):

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Email Address (Applicant):

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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 Needed:

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Equipment / Clothing Cost: $

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Amount Requested: $

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

Yes

No

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What are the other programs?

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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

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 Fund. This person should not be a relative or friend, but someone who knows your situation. Example: Social Worker, Clergy, Group Leader, Coach, Teacher, Doctor.

Are you providing a reference?(*)

Yes

No

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

Yes

No

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Please upload your latest NOA

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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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Authorized Signature: (*)

Sign Above

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Date:

December 21, 2024

Security check(*)

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Only click Submit once. There will be a short delay while your application is being received.