Activity Registration Incentive Program

General Information About the Youth

First and Last Name *

Date of Birth *

Mailing Address *

City *

Province

Postal Code *

Proof of Residence *

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(Example : Utility bill, government-issued ID or government issued correspondence)

Parent/Guardian Name *

Telephone *

Cell Phone

Email *

Name of Association *

Start Date of the Activity

End Date of the Activity

Amount Paid *

Submit Receipt/Proof of Payment *

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Contact Person *

Telephone

Cell Phone

Email

Event Name

Date of the Event

Event Location

Submit Proof of Participation in the Event

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Contact Person

Telephone

Cell Phone

Email

Signature (parent/guardian) *