Leisure Access Program Referral Agency Application

Client(s) and Additional Household Family Members

Full Name	Date of Birth	Operations
Full Name	Date of Birth

Use the button above to add additional family members

Client Information

Phone

Address

Postal Code

Referral Agency Use

# In Household	1	2	3	4	5	6
Income Under	$25,146	$31,304	$38,484	$46,726	$52,996	$59,771

I authorize that the applicant(s) listed above are eligible and qualify for the City of Prince George Leisure Access Program.

Staff Name

Date

Staff Phone

Staff email

Verified Residency

Verified Financial Eligibility

Identify The Referral Agency You are representing

Agreement

The personal information on this form is collected by the City of Prince George for the purpose of registration in the Leisure Access Program and communication about the program, under the authority of section 26(c) of the Freedom of Information and Protection of Privacy Act. If you have any questions about the collection of information, please contact the Manager, Aquatics or Supervisor, Civic Initiatives and Partnerships at 1100 Patricia Boulevard, Prince George, BC, by telephone (250-561-7600 or 311), or email leisureaccessprogram@princegeorge.ca.

I agree to and acknowledge all the terms of this application