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

Number of household members*

Primary Contact Information

First Last

Child or Adult?

Child
Adult

Household Member #2

First Last

Child or Adult?

Child
Adult

Household Member #3

First Last

Child or Adult?

Child
Adult

Household Member #4

First Last

Child or Adult?

Child
Adult

Household Member #5

First Last

Child or Adult?

Child
Adult

Household Member #6

First Last

Child or Adult?

Child
Adult

Household Member #7

First Last

Child or Adult?

Child
Adult

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.

One person 23,549 | Two people 29,316 | Three people 36,041 | Four people 43,759 | Five people 49,631 | Six people 55,976 | Seven people 62,321

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