GabRec Access Pass Registration – Gabriola Recreation Society

Step 1: Application Information

Please list each person living in the household.

Address*

Street Address City Province Postal Code

Primary Phone Number

Additional Phone Number

Number of household members*

Primary Contact Information

First Last

Gender

Male
Female
Prefer Not to Answer

Date of Birth

Household Member #2

First Last

Gender

Male
Female
Prefer Not to Answer

Date of Birth

Household Member #3

First Last

Gender

Male
Female
Prefer Not to Answer

Date of Birth

Household Member #4

First Last

Gender

Male
Female
Prefer Not to Answer

Date of Birth

Household Member #5

First Last

Gender

Male
Female
Prefer Not to Answer

Date of Birth

Household Member #6

First Last

Gender

Male
Female
Prefer Not to Answer

Date of Birth

Household Member #7

First Last

Gender

Male
Female
Prefer Not to Answer

Date of Birth

Step 2: For your information

The GRS asks that successful applicants for the GabRec Access Pass are in general accordance with the Statistics Canada Low Income Cut-Offs (LICO's). If the combined incomes of your household correspond with the amounts listed below based on the number of people living in the household please sign the designated line.

1 Person: $20,822 | 2 People: $25.921 | 3 People: $31,866
4 People: $38,691 | 5 People: $43,833 | 6 People: $49,493
7 People: $55,105

I certify that the combined income levels of my household are in general accordance with Statistic Canada's LICO's*

Yes

Name (Signature)*

Date

Step 3: Consent / Declaration

I hereby certify that I am:
A) A resident of Gabriola
B) 18 years or older (save special circumstance)

Name (Signature)*

Date