Subsidy Application Form

Kitsilano Neighbourhood House is committed to ensure that financial circumstances do not prevent anyone from participating in our programs. In order to apply for program subsidy, please complete this form. All applications will be kept in strict confidence. Please note !ome programs have limited subsidy available. "or child care # seniors housing, there is a separate application process. Please contact our "ront $esk %orker at &'()*+&)+,-- or frontdesk.kitshouse.org

Name of Program ////////////////////////////////////// Name of Applicant ////////////////////////////////////// Phone 0 /////////////////////// 1mail /////////////////////////////////

$o you have an active Kits House 2embership3

4es

No

5otal amount due 5otal amount you can pay

6////////////// 7A8 6////////////// 798

5otal !ubsidy :e;uested

6////////////// 7A)98

Applicant !ignature ////////////////////////// $ate //////////////////////