Required fields are marked with asterisks (*)

Department of Parks Recreation and Culture

Subsidy Fee Assistance Application Form

Confidental Information

Applicant must be a Municipality of Port Hope Resident - please read the Port Hope Fee Assistance policy to determine your eligibility.

Name of Adult/Parent/Guardian:

Home Phone #

Cell/Work #

Address/City:

Postal Code:

Email Address:

Name (Family Member 1):

Date of Birth:

Occupation or School

Name (Family Member 2):

Date of Birth:

Occupation or School

Name (Family Member 3):

Date of Birth

Occupation or School

Name (Family Member 4):

Date of Birth:

Occupation or School

Name (Family Member 5):

Date of Birth:

Occupation or School

Total Household Income and Assets:

I agree that the above information supplied with this application is true and correct.

Signature of Applicant(S)

Clear

Date of Signature: