P.R.O. Kids

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For youth from 2 to 18 years of age. This is a service for Dieppe and Memramcook residents. Applications are considered on a first come, first serve basis. Help to complete this application is available.

Information

Name of child/youth

Choose an option

Boy

Girl

Birth date

Name of parent/guardian

Address

City

Postal code

Telephone

Email

Program/activity (sport, recreational and cultural)

Activity (1st choice)

Activity (2nd choice)

Season

Fall

Winter

Spring

Summer

Equipment

Will the child be registered in any other paid sport, recreational and cultural program?

Yes

No

Number of adults living at home

Number of children living at home

What is your annual household income?

Less than $29,999

$30,000 - $49,999

$50,000 or more

How do you know about the P.R.O. Kids program?

Are you in one or several of the following situations?

Social assistance program

Public housing

Unemployed

Low income

Single earner

Child support

Two references - Please provide two references (other than family members) that are familiar with your family and financial situation. (Example: teacher, coach, social worker, neighbor, doctor or nurse.)

Name of the first reference

Telephone

Relationship to the family

Name of the second reference

Telephone

Relationship to the family

I authorize the above references to release personal information as required for the registration to P.R.O. Kids. I assume full responsability for the supervision of my child while participating in activities.

Yes

No

Name of respondant

Date

Personal information contained on this form is gathered under the authority provided by the Right to Information and Protection of Privacy Act and the Personal Health Information Privacy and Access Act. This personal information will be used for the child's registration in the P.R.O. Kids program. Contact the Clerk's office of the City of Dieppe at 877.7900 for any questions regarding the collection of this data.

125CLV03.18

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P.R.O. Kids