Online Application Form

This is a Confidential Service, Please ensure you have read the Guidelines.
Forms Must be Competed in Full.

STEP 1: PRE QUALIFICATION:
Have you applied to other organizations and/or foundations for financial support for this calendar year?

Have you applied to other organizations and/or foundations for financial support for this calendar year? Yes No
If yes, amount of money received?
Funded by:
STEP 2: CHILD INFORMATION
Name Child/Youth: * First Last
Birth Date * / DD / MM YYYY
Age *
Gender *

Gender Female Male
If your child currently participating in an activity?

If your child currently participating in an activity? Yes No
If Yes - Which Activity:
If Yes, please provide start and end dates:
Have you received funding in this calendar year?

Have you received funding in this calendar year? Yes No
If Yes, Amount of money received:
Funding by:

Funding by: Prokids Kid Sport Canadian Tire Jumpstart Other
If other, please specify:
STEP 3: PROGRAM INFORMATION
Activity:
How long is this activity (eg. 8 weeks, 10 weeks, etc.)
Name of Organization:
Organization Contact Name:
Phone - ### - ### ####
Are there tryouts?

Are there tryouts? Yes No
If Yes indicate date: / DD / MM YYYY
Registration Fees Only: $ . Dollars Cents
Do not include insurance, tryout fees, uniforms, tournaments, transportation or equipment)
STEP 4: PARENT/GUARDIAN INFORMATION:
Name of Parent/Guardian 1: *
Name of Parent/Guardian 2: *
Complete Mailing address: *
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Ensure information is Accurate or Could result in Processing Delays
Phone Day * - ### - ### ####
Phone Evening - ### - ### ####
E-Mail *

Note: We request that a current email address be provided as the results of your application wil be sent electronically.
Number of children 18 & under living in the household:
Please check the options that apply to you:
2 Parents/Adults 1 Parent/Adult Foster Parent(s) Grand Parent(s) Married Common Law Separated Divorced
Occupation & Employer (Parent/Guardian 1)
Occupation & Employer (Parent/Guardian 2)
Please check the options that apply to you:
Single income family 2 income family Full time Part time Seasonal E.I. Casual/On Call Assistance Disability Child Support
Further Information may be required to complete the application process.
If you need any assistance, please call (506) 375-0814
*
I have read ALL the GUIDELINES
I authorize the above references to release personal/financial information as required for program placement with P.R.O. Kids to collect the information. I further authorize P.R.O. Kids to collect this information. My signature (and/or type signature) also verifies that financial assistance is required from P.R.O. Kids in order for my child to participate. In addition, I assume full responsibility for the supervision of my child while participating in activities. I further understand that P.R.O. Kids is not liable for any injuries, loss or death as result of participation in registered recreation activities.
*
I agree.
Signature
Date * / DD / MM YYYY
Upload a File

Attach Files Attach Files
Click Submit below to complete your application.

Personal information on this form is collected under the Personal Information Protection and Electronic Documents Act (PIPEDA) to maintain a record of individuals participating or utilizing courses, activities or facilities. Questions can be directed to Western Valley P.R.O. Kids (506) 375-0814.

For further information, e-mail: kent.kuhn@gnb.ca.

Online Application Form

Online Application Form

STEP 1: PRE QUALIFICATION:

STEP 2: CHILD INFORMATION

STEP 3: PROGRAM INFORMATION

STEP 4: PARENT/GUARDIAN INFORMATION:

Further Information may be required to complete the application process.

If you need any assistance, please call (506) 375-0814