2017 Canadian Tire Jumpstart Application Form

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1 2017 Canadian Tire Jumpstart Application Form The Canadian Tire Jumpstart Program supports getting kids in the game by assisting with the costs associated with registration, equipment and/or transportation for sports and physical activity programming. Jumpstart helps kids between the ages of 4 to 18 years who are enrolled in an eligible program (i.e. Boys and Girls Club of Leduc) for a minimum of 5 consecutive weeks. Funding is available for children (whose families qualify) to a maximum of $400 per year per child. $ will be allocated for January 1 to May 31, and the additional $ from June 1 to November 30. Once funds are depleted, no further funding can be accessed, for any additional sport or activity until the following calendar year. You must reapply for funding for each calendar year funding is required following the current one. A bond cheque or PAD agreement must be provided in the amount applied for. If you abide by the terms of this agreement (see Section 3), your bond cheque or PAD Agreement will be destroyed. SECTION 1: Reason for Application In order to ensure the Jumpstart Program in utilised as intended, families must demonstrate financial hardship. One of the circumstances below is required for the application to be submitted. Please select at least one: Applicant receives AISH, Alberta Child Health Benefit, or Alberta Works assistance. Applicant meets income threshold requirements. (see Table #1) Applicant has extenuating circumstances that have caused the applicant to request Jumpstart assistance (Please briefly outline in the space provided below). See next page and complete work table at the top to determine if you qualify financially for funding as per Table # 1 on the same page. 1

2 2017 Canadian Tire Jumpstart Application Form How does an applicant determine their income? You can calculate total income for the household by referring to the latest income tax returns for all income earners in the household. Work Table to determine financial qualification Add all gross employment incomes for all working members in the household: Add child support receipts for the year: Add other gross income from pensions, RRSP withdrawals, Employment Insurance, social assistance, AISH, etc. TOTAL of all income/receipts noted above: Refer to the table below and select the line that identifies your family situation. If the amount to the right exceeds the amount on the line for your family situation, you may not qualify financially for Jumpstart assistance unless extenuating circumstances are applicable as outlined in Section 1 on Page 1. Family Type/Scenario Table #1: Income Thresholds for Jumpstart Maximum Qualifying Income Single parent with 1 child 2 persons $29,440 Single parent with 2 children 3 persons $36,193 Single parent with 3 children 4 persons $43,942 Single parent with 4 children 5 persons $49,839 Single parent with 5 children 6 persons $56,209 Single parent with 6 children 7 persons $62,581 Couple with 1 child 3 persons $36,193 Couple with 2 children 4 persons $43,942 Couple with 3 children 5 persons $49,839 Couple with 4 children 6 persons $56,209 Couple with 5 children 7 persons $62,581 If there are more than 7 persons living in your household add $6,362 to the applicable maximum qualifying income for each additional person. Exceptions Sometimes a family can be eligible if their income is higher than the amounts in the table above. Such circumstances include a significant drop in income during the last year, illness, unexpected economic hardship or other issues representing a barrier to the child accessing recreation. 2

3 2017 Canadian Tire Jumpstart Application Form SECTION 2: Application Information & Funding Requests Name of Parent(s)/ Guardian(s): Street Address: City: Province: Postal Code: Land Phone: Cell Phone: Address: Application Date (dd/mm/yy) May the Canadian Tire Jumpstart Foundation contact you directly? Yes No 1 st Child s Name Date of Birth (dd/mm/yy) 2 nd Child s Name Date of Birth (dd/mm/yy) 3 rd Child s Name Date of Birth (dd/mm/yy) 4 th Child s Name Date of Birth (dd/mm/yy) 3

4 SECTION 3: Applicant Certification 2017 Canadian Tire Jumpstart Application Form I certify that all information I have given in regards to this application (including my current financial situation) is correct and can be substantiated. I give permission for the Boys and Girls Club of Leduc to apply to the Canadian Tire Jumpstart Program, on my behalf, for the amount indicated above (in SECTION 2). I acknowledge that this amount will be deducted from my Canadian Tire Jumpstart maximum allotment and paid directly to the Boys and Girls Club of Leduc. I understand that my application is subject to approval by the Canadian Jumpstart Program, and if declined for whatever reason, I will be responsible for paying all fees owed to the Boys and Girls Club of Leduc for the service listed above. I will discuss my options for payment with the Boys and Girls Club of Leduc administrative assistant or program director. It is my responsibility to ensure that my child attends all programming for which he/she is registered. I understand that if my child does NOT attend a program for which I have received Jumpstart funding, I will be responsible for reimbursing Jumpstart for all fees associated with the Program. I understand that I will be ineligible for future funding from Jumpstart, until this amount is paid back in full. In addition, if I cancel my child s membership and/or programming attendance before programming starts, but after the Jumpstart application has been processed, I agree that my bond cheque/pad Agreement will be cashed. A cheque for each application amount noted above must be attached to this document before the application will be processed. If no cancellation occurs the cheques will be destroyed at the end of the membership year. Canadian Tire Jumpstart and its members will respect the confidentiality of all applicants. By completing this application, I hereby authorize Canadian Tire and its local Canadian Tire Jumpstart Chapter to consult with the Boys and Girls Club of Leduc and share this information as needed. I understand if I do not act in accordance with all the provisions of this agreement, that I risk becoming ineligible for future Jumpstart funding. Parent/Guardian Signature: Date: Executive Director or Designate Approval: Date FOR OFFICE USE ONLY Application Received (dd/mm/yy) / / Application Completed (Y/N): Accepted (Y/N): Reason: First Time Funding (Y/N): Amount: $ (Bond Cheques/PAD Agreements received for amounts requested) Allocation Period: Semester 1 Submission Number Semester 2 Application Number: Note to Staff: Boys and Girls Club of Leduc staff will assist the applicant with completing these applications and ensure all applicants submitted for approval meet program eligibility requirements. 4

5 Pre-Authorized Debit (PAD) Agreement Boys & Girls Club of Leduc 102, 4330 Black Gold Drive Leduc, AB, T9E 3C3 (780) Definitions: In this Agreement: I, We, Our, Me, My, Us, Payor refers to the person(s) signing this Agreement. Pre-Authorized Debit (PAD): means a pre-authorized debit payment item in electronic form drawn pursuant to this Agreement on my/our account at my/our Financial Institution (FI). Operation: I/We understand and undertake that: 1) This authorization is for the benefit of the Boys and Girls Club of Leduc (the Company) and my/our FI where I/we have my/our account. My/our FI agrees to process debits against my/our account in accordance with the rules of the Canadian Payment Association (CPA); 2) Giving this authorization to the Company is the same as giving it to my/our FI; 3) My/our FI is not required to verify that the PAD conforms with my authorization; 4) My/our FI is not required to verify that the purpose of payment to which this PAD related has been fulfilled; 5) Revoking this authorization does not terminate any contract between me/us and the Company. My/our authorization applies only to the method of payment and has no bearing otherwise on the contract. Pre-Notification: The Company and I/us agree to hereby waive all notification requirements from the Company for the variable amount PADs. Cancellation: I/we may revoke my/our authorization at any time, subject to providing notice of at least 10 days prior to the next debit due date. I/we must advise the Company in writing or by signing the cancellation area below. To obtain a sample cancellation form, or for more information on my/our right to cancel a PAD agreement, I/we may contact my/our FI or visit The Account: I/we confirm that: 1) All persons required to sign on my/our account with my/our FI have signed this agreement; 2) I/we certify that all of the personal and account information recorded in this Agreement is correct. I/we will inform the Company in writing of any change to such information at least 10 business days prior to the next due date of the PAD. Dispute and Reimbursement: I/we have certain recourse rights if any debit does not comply with this Agreement. For example, I/we have the right to receive reimbursement for any debit that is not authorized or is not consistent with this PAD agreement. To obtain more information on my/our recourse rights, I/we may contact my/our FI or visit I/we understand that: 1) I/we may dispute a PAD and may claim for reimbursement if: a) The PAD was not drawn in accordance with this Agreement; or b) The Agreement was revoked; or c) No Agreement exists between me/us and the purported payee. 2) If I/we are claiming reimbursement, I/we must, within 90 calendar days of the date of posting of a Personal PAD or Funds Transfer PAD or 10 business days in the case of a Business PAD, complete a declaration to my/our FI that I/we have a claim for one of the reasons given in the preceding paragraph; 5

6 Pre-Authorized Debit (PAD) Agreement Boys & Girls Club of Leduc 102, 4330 Black Gold Drive Leduc, AB, T9E 3C3 (780) ) In the case where the declared condition is no Agreement exists between me/us and purported Payee, I/we may claim reimbursement within 90 calendar days after the posting date on my/our account statement which shows the improperly processed debit; 4) Any claim relating to a PAD which is advanced after the expiry of the time in the preceding paragraph or any Funds Transfer PADs is strictly a matter between me/us and the Company. I/We authorize the processing of a PAD through my/our account as detailed below: Payor Name(s): (Your Full Name as it is on your Bank Account) Payor Address: City: Province: Payor Postal Code: Payor Phone: Name of FI: (Customer s Bank, i.e., ABC Bank) Address of FI: Phone of FI: MICR Field Information (Please attach a voided cheque if possible.) Branch/Transit # Bank/Inst # Account # Type of Service: Personal Business Payment for: Jumpstart Fees for Semester 1 if they are declined by the Jumpstart Foundation after an application has been submitted by the Boys and Girls Club of Leduc. The amount declined by the Jumpstart Foundation will be the amount entered into the Amount field below and will be deducted from my bank account as noted above. Frequency Check 1 only One-Time Monthly Semi-Monthly Weekly Bi-Weekly Other - Specify X Amount: $ Start Date: End Date: Jumpstart Fees for Semester 2 if they are declined by the Jumpstart Foundation after an application has been submitted by the Boys and Girls Club of Leduc. The amount declined by the Jumpstart Foundation will be the amount entered into the Amount field below and will be deducted from my bank account as noted above. Frequency Check 1 only One-Time Monthly Semi-Monthly Weekly Bi-Weekly Other - Specify X Amount: $ Start Date: End Date: I/We understand and agree to the terms and conditions of this Agreement. Date: Signature: Date: Signature: Authorization to cancel PAD Signature: Date: Boys and Girls Club of Leduc 102, 4330 Black Gold Drive Leduc, AB, T9E 3C adminassistant@bgcleduc.ca 6

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