P.R.O. Kids
-- APPLICATION
For
Children & Youth up to 18 years of age
ü This is a service for Riverview Residents Only
ü Please complete both sides of this application.
ü Applications are considered on a first come, first
served basis.
1. APPLICANT
INFORMATION
Name of
Child / Youth_____________________________________
Birthdate_______________________
Name of
Parent/Guardian
_________________________________________________________________
Address
______________________________________________________Postal
Code_______________
Telephone
(Day) _____________________________ (Evening)__________________________________
2. PROGRAM INFORMATION:
If you have chosen a specific program in the community, fill
in the details.
If you are not aware of a program, name the activity and we will try to
find a suitable program for you.
1st Choice 2nd Choice
Activity or Sport_____________________________ Activity
or Sport____________________________
Organization offering this
activity: Organization
offering this activity:
_____________________________________ ______________________________________
Program Dates Program Dates
From:________________ To:___________________ From:________________ To:_________________
Is the child / applicant
registered in any other recreation / art / cultural / sport program?
____No ____ Yes Describe:__________________________________________________
How can you assist the P.R.O. Kids
Program? _____Volunteer Driver
_____Fundraising Committee
_____Cash Donation Other_________________
3. THIS FORM HAS BEEN COMPLETED BY:
Name ____________________________________Telephone:
__________________________
4. REFERENCE:
Please provide a reference that is
familiar with your situation and who can verify that you require help from
P.R.O. Kids. This person should be an
adult who knows the child, is not the parent and who is active in community
activities.
(Example: Teacher,
Coach, Clergy, Social Worker, Group Leader etc., NOT a family member)
Name of
Reference ___________________________________ Tel. (day)____________________
Address
____________________________________________ Tel. (evening)_________________
I,
__________________________________________ authorize the above reference to
release personal information as required for program placement to P.R.O.
Kids. I further authorize
P.R.O. Kids
to collect this information. My 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.
Signature
___________________________________ Date __________________________________
Personal
information on this form is collected under the authority of the Municipal Act,
and will be used to maintain a record of individuals participating or utilizing
courses, activities or facilities.
Questions can be directed to the P.R.O. Kids Coordinator,
Riverview
Parks & Recreation, 30 Honour House Court, Riverview, NB E1B 3Y9
(506) 387-2051
COMMENTS:___________________________________________________________________
____________________________________________________________________________
Please mail or drop off this completed form to:
P.R.O. Kids
Riverview Parks & Recreation
Department
30 Honour House Court
Riverview, NB E1B 3Y9
This is a confidential service offered by the Riverview Parks &
Recreation Dept.
For more information contact the P.R.O. Kids Coordinator, Karen @
387-2051
|
FOR OFFICE USE ONLY |
|
DATE RECEIVED: |
The P.R.O. Kids concept was developed by
the City of Thunder Bay