Colchester / East Hants Canadian Tire Jumpstart Chapter

Colchester / East Hants
Canadian Tire Jumpstart Chapter
Canadian Tire Jumpstart helps financially disadvantaged kids
get involved in organized sport and recreation by covering the
costs of registration fees.
Our goal is to help those children that would not be able to
participate in a physical activity without the assistance of the
Canadian Tire Jumpstart program.
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 Parents/Guardians can apply for children aged
- 18.
 The program is open to individual children, not groups or
teams.
Contact Name: Stephanie Milbury
Organization Name: Town of Truro
Address: 40 Douglas St.
City: Truro, Prov.: NS, Postal Code: B2N 2E7
Email: [email protected]
Phone: 902-893-6078
Contact Name: Corrine Giles
Organization Name: Municipality of East Hants
Address: 230-15 Commerce Court
City: Elmsdale, Prov.: NS, Postal Code: B2S 3K5
Email: [email protected]
Phone: 902-883-7098 X144
 Funding is available for multiple children within the same
family for the same season.
 Funds are awarded for registration fees.
 Grants are available for up to $300 per child per session.
 Funding is available for any sustained program that lasts a
season.
 Funding must be for on-going activities or programs.
 Children can apply for successive seasons in an activity, up
Contact Name: Michelle Misener
Organization Name: Big Brothers Big Sister
Address: 26 Logan Street
City: Truro, Prov.: NS, Postal Code: B2N 3K3
Email: [email protected]
Phone: 902-895-4562
Other Information
Application Forms can be found at the Canadian
Tire Store (will also accept completed application)
at 90 Robie Street Extension, Truro, B2N 1L1.
Online at:
Town of Truro – www.truro.ca
Municipality of East Hants – www.easthants.ca
Village of Bible Hill – www.biblehill.ca
Municipality of Colchester – www.colchester.ca
to a maximum of $600 per year.
 Priority is given to recreational over competitive sports/
activities
 Incomplete application forms will be sent back for
completion.
 Applicants will be contacted no later than four (4) weeks
after the deadline notifying them of the status of their
application.
 Multiple sports can be applied for in one session within
the $300 maximum.
 Grants are made payable to a league, association or club.
January 15
April 15
June 15
October 15
Colchester / East Hants
Canadian Tire Jumpstart
Chapter
Canadian Tire Jumpstart Application Form - Colchester / East Hants Chapter
Please ensure this form is fully completed.
PARENT / GUARDIAN INFORMATION
REFERENCE INFORMATION
Parent / Guardian Name
Please provide a reference that is familiar with
your situation and who can verify that you require
assistance. This person must be a non-family
member. They can be an employer, police officer,
teacher / principal, counselor, social worker, coach
or clergy member.
Mailing Address
City / Town
Prov.
Home Phone
Other Phone
Email
Relationship
Household (HH) Details
Number of Children in HH: ______
Postal Code
Size of Household ____ 1 Parent ____2 Parent
Signature of Parent / Guardian
Date
Name
Position
Day-time Phone
CHILD / YOUTH INFORMATION
Email
Child / Youth Name
Gender
Mailing Address
Postal Code
Relationship
I support the request on behalf of the youth named
whose need is consistent with the Canadian Tire
City / Town
Prov.
Home Phone
School Name
Signature
Age
Date of Birth
Date
SPORT / RECREATION INFORMATION
CONFIDENTIALITY
Sport / Recreation
Activity Requested
All information is kept confidential.
Program Duration
Start:
End:
Organization Name
Contact
Mailing Address
Phone
City / Town
Prov.
First time participating in
this activity?
_____ Yes _____No
If No, for how many years?_________
GRANT REQUEST (Expenses the grant will be used for)
Registration Fees
CANADIAN TIRE STORE LOCATION
# Wks
$
Is there a Store
in your area?
Postal Code
______ Yes ______ No
If no, please
indicate the
nearest store.
OFFICE USE ONLY
Received
Total Request
Previous Canadian Tire
Jumpstart Support?
$
Has your child received Jumpstart funding? ______ No ______ Yes
If yes, when?
Will you be applying for
Kidsport funding?
___________ Yes
___________ No
Decision
Amount
Cheque #
Cheque Date
□ Approved □ Declined