Child's name *

First Name

Last Name

Date of birth *

MM

DD

YYYY

Parent Information *

First Name

Last Name

Phone *

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Program that you are applying for financial support for:

Summer Camp

PD Day Camp

Holiday Camp (Winter or March Break)

Other

For Financial Bursary Program: I confirm that our gross annual family income is less than $50,000 and can email our Canada Child Benefit Statement if requested.

Yes

For Truth and Reconciliation Program, can you provide a copy of the children's Indian Status Card?

Yes

No (Please explain below)

Percentage of program fees that you are applying for support for: *

25%

50%

75%

100%