Programs / Divisions:
Canadian Tire Boot Jumpstart Chapter
APPLICATION
A. CHILD'S INFORMATION (Please Print)
Childfs Name:
Address:
City & Postal Code:
Telephone Number: Date of Birth:
Male Female
Have you previously received Canadian Tire Jumpstart Funding or a similar type of funding?
Yes No If yes, how many times? ________
Sport for which the Canadian Tire Jumpstart grant will be used:
Name of League, Local Association or Club:
Mailing Address:
Contact Person:
Telephone: Email:
Is this the first time participating in this sport? Yes No
If no, how many years has he/she been involved?
B. FUNDING REQUEST:
Please indicate for which of the following the grant will be used.
Enter the corresponding amount required.
1. Registration/Participant fees $
2. *Personal Sport Equipment $
3. Add lines 1+2 (Total Request) $
*If you chose (2), please specify what sports equipment will be needed and the cost of the
individual equipment: (ie. shinpads, softball glove, etc)
Would you be able to pay part of the above
If Yes, specify amount __________________
C. PARENT/GUARDIAN INFORMATION (to be completed by an Adult)
Mother: Father:
Address: Address: _____
City & Postal Code: City & Postal Code:_________________
Telephone Number: Telephone Number:
Occupation: _______________ Occupation: _________________
Income: Income:
Number of children in the family:
Current Financial Status of Parents/Guardians:
a) Please check one of the following which best indicates the gross household annual income.
Below $10,000/yr $10,000
$20,000
Above $40,000/yr
b) Do any of the following apply? If so, please check the appropriate boxes.
Social Assistance Single Parent Special Needs Child
Signature of Parent/Guardian: Date:
Please Forward Completed Application To:
Jeannette Lundrigan, Chairperson
Fund Disbursement Committee
Telephone: (709) 891-2309 (Home) or (709) 891-5027 (Work):
E
Confidentiality of all recipients will be protected
