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Agency Direct Referral Application Sign Off
Please complete all information.
Step 1 of 4
25%
Participant Information (Child's Information)
First Name:
*
Last Name:
*
Gender:
*
Phone:
*
Date of Birth
*
Date Format: YYYY slash MM slash DD
Address
*
Street
City
Postal Code
Parent/Guardian/Adult Information:
First Name:
*
Last Name:
*
Relationship to Child:
*
Parent/Guardian/Adult Email Address:
*
Number of Adults in the home:
1
2
Number of Children in the home:
1
2
3
4
5
6
7
8
Address:
Street
City
Postal Code
Home Phone:
*
Work Phone:
Cell Phone:
Program Information: ALL information must be provided):
Program:
*
Organization/Club:
*
Organization Contact:
Organization Email:
Club Mailing Address:
Street
City
Postal Code
Start Date:
*
Date Format: YYYY slash MM slash DD
Program End Date:
*
Date Format: YYYY slash MM slash DD
Registration Fee:
*
Discount from Organization/Club:
Amount requested from youthreach (typical grants are $250 per participant annually):
*
If possible attach a photo or scan of program provider’s registration form with this application so payment can be linked to your child’s registration fees.
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Agency Referral/Endorsement:
The Agency representative endorsing this form with their signature acts as an objective third party who is familiar with the family, can confirm specifics regarding the participant, the program and is in a professional position to assess financial barriers facing the family based on current documents on file at your organization.
Name:
*
Organization:
*
Position:
*
Email:
*
Phone:
*
Please select one of the following options to verify that the applicant’s total household income is $50,000 per year or lower:
My organization has one (1) of the following Government or Proof of Income documents on file related to YouthReach Funding of participants living in the household facing financial challenges:
• Income Tax – Notice of Assessment, for all family members over the age of 18 (living in the household)
• ODSP Statement
• Ontario Works Statement
• Old Age Security & CPP Statement
Todays Date
Date Format: MM slash DD slash YYYY
Based on recent discussions with the applicant(s) to YouthReach regarding financial challenges facing their household I can confidently endorse this application knowing there is a legitimate need for support and the participant will not be able to participate in the program outlined in this application without the financial support of YouthReach.
Todays Date
Date Format: MM slash DD slash YYYY
In consideration for any funding or other services provided by YouthReach, the parent or guardian of the participant is aware of the registered activity and supports this application for funding. They hereby release YouthReach from all claims that they or their child may have with respect to the activity that funded by YouthReach. By submitting this application, I voluntarily agree with this statement in its entirety. The parent or guardian also agrees to future inquiries from YouthReach regarding the success of their child’s experience in order to track success stories and positively impact fundraising efforts.
I Agree
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