Drum Life Pass Application A. Proof of Eligibility Recipients of the Drum Life Pass must be: Residents of Drumheller - Starland County for subsidized counselling program; Be a Canadian citizen, permanent resident, or have a closed work permit; And have an annual income below the income threshold. Proof of Residency (minimum of one) * Driver's License Lease Agreement Financial Information (copy of bill with your name/address) Citizenship (select one) * Canadian Citizen Permanent Resident Other Household (select all that apply) * Single Married/Common Law With Children Proof of income must be provided for all adult household members. Preferred sources being: * Notice of Assessment showing line 23600 net income issued by Canadian Revenue Agency AISH Health Benefits Card (or other provincial government document showing that you are currently receiving AISH) Government documentation showing income support: Alberta Works, Alberta Seniors Benefits B. Applicant (must be aged 18+) First Name * Last Name * Address * Date of Birth * City * Province * Postal Code * Email Address Phone Number * Emergency Contact Name * Emergency Contact Relationship to Applicant * Emergency Contact Phone Number * C. Additional Family Information Please list all family members included in this application. Family Member Name Relationship Date of Birth (MM/DD/YYYY) Family Member Name Relationship Date of Birth (MM/DD/YYYY) Family Member Name Relationship Date of Birth (MM/DD/YYYY) Family Member Name Relationship Date of Birth (MM/DD/YYYY) Family Member Name Relationship Date of Birth (MM/DD/YYYY) D. I would like to apply for the following programs: Select all that apply: * Recreation Fee Assistance Program Volunteer Tax Program Hot Meals (55+) Home Support (55+) Older Adult Program Subsidy (55+) E. If approved, select which form of Recreational Facility membership you would like your discount applied to: The costs listed below are the regular monthly costs and do not account for the 50% or 90% discount based on application approval. Single Facility (Aquaplex OR Badlands Community Facility) Youth (6-17) - $30.20 Adult (18-59) - $46.20 Family - $86.10 Senior (60+) - $30.20 Multi Facility (Aquaplex, Memorial Arena AND Badlands Community Facility) Youth (6-17) - $42.00 Adult (18-59) - $59.30 Family - $107.60 Senior (60+) - $42.00 F. Net Total Household Income Adult Household Member Name Which of the following income supports applies? Income Adult Household Member Name Which of the following income supports applies? AISH Alberta Works Seniors Benefit Income Line 236 of Notice of Assessment Adult Household Member Name Which of the following income supports applies? AISH Alberta Works Seniors Benefit Income Total Income * Add together your line 23600s to get the net total household income. I would like to receive emails regarding available programs with the Town of Drumheller Yes No G. Signature By submitting this application, you agree to the following: Any information that is false, misleading or fraudulent may make this application invalid (at the Town's discretion); You agree to the terms and conditions by submitting online, and your submission represents equivalency to your signature Signature * In signing, I guarantee that the above information provided is complete and true to the best of my knowledge and I am eligible to receive municipal funding. Date * Upload any supporitng documentation File Upload Choose File No file chosen The maximum total size of all files in a single form submission is 1 GB. File Upload Choose File No file chosen The maximum total size of all files in a single form submission is 1 GB. File Upload Choose File No file chosen The maximum total size of all files in a single form submission is 1 GB. Leave Blank