CVRD Sports & Aquatic Centres
3001 Vanier Drive, Courtenay, BC V9N 5Y2
Tel: 250-334-9622 Fax: 250-334-1042
www.comoxvalleyrd.ca
Providing Leisure Access For You (PLAY)
Form must be completed in full prior to the issuing of coupon book(s)
Name of Applicant:______________________________ Care Card #:_______________________Book #:_________
Name Spouse/Partner:___________________________ Care Card #:_______________________Book #:_________
Address: _____________________________________________City/Town:_________________________________
Postal Code:_____________________ Home Phone:_______________________
Age
Dependent Names
1.
2.
3.
4.
5.
Birth date
Care Card #
Book #
You are eligible to receive a PLAY Coupon Book when your combined gross family income is below the following income:
National Council of Welfare Estimates of Stats Canada Low-Income Cut-offs - for 2013 Play Applications
# in Household
Income Under
1
$19,375
2
$24,119
3
$29,652
4
$36,003
5
$40,833
6
$46,054
7 & over
$51,274
Coupon books will be cancelled if information provided is discovered to be false. Random checks will be done and recipients
may be asked to verify revenue i.e. Revenue Canada’s most recent tax return, GAIN or other reliable documentation.
Consent Form:
I ____________________________(signature) agree to meet with a representative of the CVRD Sports and Aquatic Centres
and will at that time disclose financial information based on my latest Revenue Canada tax return, GAIN or other reliable
documentation.
The Canadian Tire Jump Start Program may provide some funding to organizations
_____ Yes; I give permission to the CVRD Sports and Aquatic Centres to release my child’s name, city of residence, age,
gender, and activity registered in, to the Canadian Tire Jump Start program. I understand that this information is to be used by
Jump Start for verification of program registration only.
_____ No; I do not give permission to the CVRD Sports and Aquatic Centres to release my child’s name, age, birth date,
phone number and city of residence to the Canadian Tire Jump Start program.
Self Declaration:
I (print name)
that my combined family income currently is estimated at $
hereby declare on (date)
per year.
Application approved
by:______________________________________Date:__________________________________
For an appointment to complete the PLAY application please phone 250-334-9622 extension 221.
Please read the reverse of this form for further information and documentation required.
ELIGIBILITY
USE OF COUPON BOOKS
Residents of Courtenay, Comox, Cumberland,
Areas A, B, C of the Comox Valley Regional
District.
Books are valid:
For the calendar year.
The PLAY Program is designed for individuals
and families who are working low income, on
BC Benefits and/or the family income before
taxes does not exceed the amounts shown on
the application form. Applicants must meet
annual income requirements outlined on the
application form. The signed form is the
statement of annual earnings. Random checks
will be done to verify statements.
Each member of the family is entitled to one
coupon book per year.
USE PROCEDURE
Entire coupon book must be presented at
the time of use. Individual coupons are
not accepted.
HST, where applicable, and supply costs will
be participant’s responsibility.
Coupon books are not replaceable, nontransferable, not for cash and not for credit.
Coupons are not valid during super saver
sessions, as a reduced rate is in effect.
Registration in leadership courses may be
included; materials and supplies are the
responsibility of the registrant. Must be preapproved by the Manager of Recreation
Programs.
APPLICATION PROCESS
•
Adult coupon books are to be given only to
adults present at the time of distribution.
Other adults listed on the form must come in
for his/her coupon book and verify residency
and Care Card number.
At the CVRD Sports and Aquatic Centre
facilities.
Coupon books will be issued when all
eligibility requirements are met.
EACH BOOKLET CONSISTS OF
COUPONS FOR:
1 free admission per month
2 admissions per month at 75% off
2 admissions per month at 50% off
3 admissions per month at 25% off
1 free program per year
4 programs at 50% off per year
2013
P.L.A.Y.
Providing Leisure Access for You!
Application forms available at the CVRD
Sports Centre on Vanier Drive & the Aquatic
Centre on Lerwick Road or online at:
www.comoxvalleyrd.ca
Applications are processed at:
CVRD Sports Centre
3001 Vanier Drive, Courtenay
Phone 250-334-9622 ext 221 to make an
appointment.
Bring with you to the appointment:
•
•
•
•
A completed PLAY application
Proof of residency (Valid BC ID or
Drivers License or recent utility
bill)
BC Care Cards for each family
member
Recent cheque stub or Ministry
Form or Letter for Disability Status
(DB II, PWD)