Fillable LIFE Leisure Involvement for Everyone

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LIFE Leisure Involvement for Everyone

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  • 17 check-boxes
  • 30 other fields

Country of origin: CANADA
File type: PDF

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LIFE Leisure Involvement for Everyone
LIFE APPLICATION FORM 2021 FOR RESIDENTS OF THE WEST SHORE
When applying for the LIFE Program, please provide the following:
1. Current Canada Revenue NOA (Notice of Assessment) listing line 150
as it appears on the assessment. [ To obtain a copy of your NOA call
Revenue Canada at 1-800-959-8281 or visit
http://www.cra-arc.gc.ca/myaccount ]
2. Proof of current residency (i.e., valid Driver’s License or BCID, recent
Hydro or other bill showing address)
BIRTH DATE:
POSTAL CODE:
HOME PHONE: CELL PHONE:
PERSONAL INFORMATION
PRIMARY APPLICANT:
ADDRESS:
E-MAIL:
MUNICIPALITY: PLEASE SELECT ONE
Langford Colwood Metchosin
Highlands
PROGRAM OPTIONS and DEPENDANTS
POST SECONDARY STUDENTS of UVic, Royal Roads, & Camosun ARE NOT ELIGIBLE FOR THE LIFE PROGRAM
FAMILY MEMBERS
Including applicant’s name
AGE
BIRTH
DATE
PLEASE SELECT PROGRAM OPTION
52 Drop-in/
4x Registration
Discount
52 Drop-in/
50% JDF 55+ Membership
3x Registration Discount
Annual Pass or
Annual Regional Pass
50% Discount
To be eligible for participation in the LIFE Program, gross income must be within/below the following income rangeswith proof provided. Proof of
combined income will be required in circumstances for married/comon-law settings.
Low Income Cut os 2021 LIFE Program
# IN HOUSEHOLD 1 2 3 4 5 6 7 or more
INCOME UNDER $25,923 $36,660 $44,900 $51,846 $57,966 $63,499 $68,587
LIFE Cards will be cancelled if this information is discovered to be false. Random checks are done and LIFE participants will be asked to verify
revenue based on Revenue Canada’s most recent tax return. It is a serious oence to provide inaccurate information on this form.
SELF DECLARATION and CONSENT:
I hereby declare that my/our income per year is currently estimated at _________________________.
I declare all the above information to be true to the best of my knowledge.
If requested, I _____________________________________ (PRINT NAME) agree to meet with a representative of the West Shore Parks & Recreation
Society and will at that time disclose nancial information detailed on my latest Revenue Canada tax return. As a pass holder, I consent to abide by
the rules of the facilities where I participate, and I am aware that failure to do so may result in my pass being revoked. In addition, information will
be shared with other participating facilities, and a ban from one facility may be extended to all participating facilities. The information collected on
this form is collected under the authority of the Municipal Act, Section 245.
SIGNATURE: _________________________________ DATE: _________________________________
View Royal
click to sign
signature
click to edit
LIFE APPLICATION FORM 2021 FOR RESIDENTS OF THE WEST SHORE
Who Is Eligible? Residents of Colwood, Langford, Highlands, Metchosin and View Royal whose gross income is within or
below the estimated Low Income Cut O (see front of this application form).
How Do I Apply? 1. Complete one application per family and drop o at Reception at the Juan de Fuca Recreation Centre,
1767 Island Highway, Victoria BC 250-478-8384
2. Provide current proof of residency with you, such as a utility bill, rental agreement or government ID.
3. Provide 2019 or 2020 Notice of Assessment as proof of individual/gross annual family income. A copy
may be obtained through Revenue Canada at 1-800-959-8281 or http://www.cra-arc.gc.ca/myaccount
4. LIFE Cards will be issued to each member of an eligible family and are valid for one calendar year:
January 1, 2021 - December 31, 2021
CHOOSE ONE OF THE FOLLOWING DISCOUNTS
Option 1 Drop-in and Registration Discount
Receive both of the following discounts:
A. 52 Free Admissions to Drop-in Sessions at any Greater Victoria Recreation Centre
For use at West Shore, Saanich, City of Victoria, Oak Bay, Panorama, Esquimalt and SEAPARC.
• LIFE card must be presented at the time of admission.
• One card is issued once per year for each family member.
AND
B. 50% o (up to $50 reduction) 4 times a year on West Shore Parks & Recreation registered
programs or membership passes.
• Some restrictions apply.
• A ‘Registration discount’ may be used for 50% o a Juan de Fuca 55+ Senior’s Centre Membership
Option 2 Annual Pass Discount
Receive the following discount:
A 50% reduction on a West Shore Parks & Recreation Annual Pass OR a Regional Annual Pass
Annual Pass for use at West Shore Parks & Recreation facilities ONLY. Annual Regional Pass for use at 14
Greater Victoria Recreation Centres (does not include YMCA-YWCA).
• Monthly payment plans available, Visa/MasterCard/AMEX and automatic debit from your chequing
account are accepted. Please Note: a $25 admin fee will be charged upon registration of all payment plans.
*Option 2 does not receive the 50% discount o programs or membership pass 4 times a year.
Other Information:
• LIFE cards are non-transferable, and are not eligible for cash or credit.
• All eligible WSPR LIFE members may book a free JDF Weight Room orientation with Reception.
• Participants must have their picture taken for their LIFE card.
• $5 + tax replacement charge for lost cards.
The LIFE (Leisure Involvement For Everyone) program is supported by the Greater Victoria Active Communities Commitee.
FOR OFFICE USE ONLY
DATE APPLICATION RECEIVED: STAFF NAME:
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Completed 4 September 2021

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