Recreation Fee Assistance Program Application Form Personal Information - Primary Applicant First Name * Last Name * Address * Town * Postal Code * Phone Number * Email Address * I am a resident of the Town of Drumheller and have proof: Fee Assistance applications are accepted year-round, and any subsidy granted is valid for 1 year from date of approval. Please note that if you have received subsidy previously, applying for a new subsidy invalidates any previous subsidy balance remaining and these funds are forfeited. We recommend you contact the Community Development and Social Planning Manager at 403-823-1315 to review your current subsidy balance and expiry date before applying. Please upload a copy of one of the following or bring to your appointment: Government Issued Identification Current bill from a utility provider showing legal land description (e.g. home phone, gas, cable, water, energy provider); or Letter from Grace House (See Appendix A before completing the rest of this application) Choose File No file chosen The maximum total size of all files in a single form submission is 1 GB. Did you participate in the Fee Assistance Program in the past year? * Yes No If so, has your situation changed in the past year? Yes No If yes, please explain how your situation has changed (financial, living arrangements, etc.) in a way that impacts your eligibility for the program? * If no, please continue to SECTION C. Additional information will be requested if necessary. Adult Name Record amount from line 236 of Notice of Assessment Total Upload a copy of your Notice of Assessment * Choose File No file chosen The maximum total size of all files in a single form submission is 1 GB. If required, please upload an additional file Choose File No file chosen The maximum total size of all files in a single form submission is 1 GB. If required, please upload an additional file Choose File No file chosen The maximum total size of all files in a single form submission is 1 GB. If required, please upload an additional file Choose File No file chosen The maximum total size of all files in a single form submission is 1 GB. Number of people in the household dependant on this income * You may qualify through proof of income. Please see Appendix A for a list of qualifying documents. Please bring this information to your appointment. Please list yourself (primary applicant) and any others who will be a part of this application Name Birth Date (DD/MM/YY) Program/Service Requested Please list all other applicants to be included on this application Consent to Contact * May we contact you via email/phone to complete a user survey or share information about other community programs and events for families? Yes No Community Access Pass * Thank you for your interest in one of our programs. If your application is approved, you may also qualify for the following programs: Counselling Subsidy through Wheatland County Counselling Hot Meals Subsidy and Delivery Good Food Box Subsidy Tech Drive technology Would you like more information on any of these programs? By selecting yes, you are providing permission to allow the Town of Drumheller to contact you regarding the above programs. Yes No If yes, please describe: Counselling Subsidy through Wheatland County Counselling Hot Meals Subsidy and Delivery Good Foox Box Subsidy Tech Drive Technology Information Confirmation I hereby certify that the information in this application is true, correct and complete in every respect. I have fully disclosed my family’s income from all sources. Further, I agree to inform the Community Development and Social Planning department of changes in the information given. I understand that failure to do so could result in loss of this and future subsidy. I understand that this application is valid for a maximum of twelve months, and future subsidy requests will require a re-application*. The Town of Drumheller may verify any information on this application. *Applicants receiving Seniors’ Benefits or AISH will not be required to reapply on an annual basis, but will be required to renew their membership annually, by verifying any changes to their personal information. Name * Signature * Date * Privacy Personal information on this form is collected under the authority of the Freedom of Information & Protection of Privacy Act (the Act) for administrative purposes of the Town of Drumheller. Personal information is protected from unauthorized use and disclosure in accordance with the Act and may only be used and disclosed as provided by the Act. Questions regarding the collection of personal information can be directed to the FOIP Coordinator, Town of Drumheller, 224 Centre Street, Drumheller Alberta, T0J 0Y4 403-823-1339. Leave Blank