2. 

3. Dr Lander Memorial

   Swimming Pool

   Fee Assistance Application

5. Please Read the following Fee Subsidy Information

   The Town of Diamond Valley offers a Fee Assistance Program to help eligible residents access swim lessons, passes, and programs at the Dr. Lander Memorial Swimming Pool.
   
   Please read the details of the program and determine if you are eligible.

   Before completing this form, please ensure you:

   • Reside in Diamond Valley or a nearby area of Foothills County

   • Meet the qualifying income levels

   • Have supporting documents ready to upload (e.g., Notice of Assessment or alternate proof of income)

   Applications are accepted between April 15 and July 30, or until the available funds are fully allocated. Rebates are issued after approval and are valid only for the current pool season.

   If you have questions or need help completing this form, please contact the Community Services Department at 403-933-4348.

7. Name*

   First and last name of the applicant.

9. Email*
10. Phone Number*
12. Street Address*
14. Address (Mailing)*
16. City*
17. Province*
18. Postal Code*
22. Adult Household Members

    In order to determine eligibility for Fee Assistance, please list all family members in the home; whether they will be applying for or using the subsidy or not.

24. How many adults in the household?*

    1. 1
    2. 2
    3. 3
    4. 4
    5. More
26. Adult 1 (A1) Full Name*
27. (A1) Relationship*

    1. Applicant
    2. Spouse / Partner
    3. Other Family
    4. Other
28. (A1) Birthdate*
    (A1) Birthdate
29. (A1) Total Annual Income (line 150 of NOA)*
31. (A1) Would you like to request fee subsidy for this person?*

    1. Yes
    2. No
33. Adult 2 (A2) Full Name*
34. (A2) Relationship*

    1. Applicant
    2. Spouse / Partner
    3. Other Family
    4. Other
35. (A2) Birthdate*
    (A2) Birthdate
36. (A2) Total Annual Income (line 150 of NOA)*
38. (A2) Would you like to request fee subsidy for this person?*

    1. Yes
    2. No
40. Adult 3 (A3) Full Name*
41. (A3) Relationship*

    1. Applicant
    2. Spouse / Partner
    3. Other Family
    4. Other
42. (A3) Birthdate*
    (A3) Birthdate
43. (A3) Total Annual Income (line 150 of NOA*
45. (A3) Would you like to request fee subsidy for this person?*

    1. Yes
    2. No
47. Adult 4 (A4) Full Name*
48. (A4) Relationship*

    1. Applicant
    2. Spouse / Partner
    3. Other Family
    4. Other
49. (A4) Birthdate*
    (A4) Birthdate
50. (A4) Total Annual Income (line 150 of NOA)*
52. (A4) Would you like to request fee subsidy for this person?*

    1. Yes
    2. No
54. If there are more than four adults living in the home, please list Names, Relationship, Birth date, & Income for each*
56. Are any of the adults listed enrolled in a post-secondary institution, and attending in person?*

    1. Yes
    2. No
58. Please specify the post-secondary institution below.*
60. Children - Under 18 living in the family home
62. Do you have children 18 (attending high school) and under?*

    1. Yes
    2. No
63. How many children in the household?*

    1. 1
    2. 2
    3. 3
    4. 4
    5. More
65. Child 1 (C1) Full Name*
66. (C1) Birthdate*
    (C1) Birthdate
67. (C1) Request Subsidy*

    1. Yes
    2. No
69. Child 2 (C2) Full Name*
70. (C2) Birthdate*
    (C2) Birthdate
71. (C2) Request Subsidy*

    1. Yes
    2. No
73. Child 3 (C3) Full Name*
74. (C3) Birthdate*
    (C3) Birthdate
75. (C3) Request Subsidy*

    1. Yes
    2. No
77. Child 4 (C4) Full Name*
78. (C4) Birthdate*
    (C4) Birthdate
79. (C4) Request Subsidy*

    1. Yes
    2. No
81. Additional Children*

    To apply for subsidy for additional children, please list their name(s) and birthdate(s) here.

83. Do you share custody of children with other parents?*

    1. Yes
    2. No
85. If you share custody of children, please provide details.*
87. Proof of Eligibility*

    You must provide proof of income for each adult listed on your application.  

    1. CRA Notice of Assessment (showing line 23600 - Net Income)
    2. Alberta Works Health Card showing month
    3. Alberta Works Child Health Benefit annual approval letter (not the card)
    4. Independant Youth letter (a letter from school principal, guidance counsellor, or Child and Youth Support Program of Alberta Children's Services)
    5. Letter from a community agency confirming current family income falls within income guidelines
    6. Other (e.g. letter explaining situation with proof of current income enclosed)
89. (A1) Proof of Income / Eligibility*
91. (A2) Proof of Income / Eligibility*
93. (A3) Proof of Income / Eligibility*
95. (A4) Proof of Income / Eligibility*
97. Attach any other relevant documentation
99. Agreement
101. Consent to Contact*

     May we contact you via email to complete a user survey or share information about other community programs and events for families?

     1. Yes
     2. No
103. Protection of Privacy Act

     The personal information collected through the Dr Lander Memorial Swimming Pool Fee Assistance Application form is for the purpose of assessing and approving the application for financial assistance. This collection is authorized under section 4(c) of the Protection of Privacy Act. For questions about the collection of personal information, contact the Privacy Office LegislativeServices@DiamondValley.town or 403-933-4348

105. Agreement*

     I give the Town of Diamond Valley permission to check the information within this application.

     ·  The Town of Diamond Valley may contact me in matters pertaining to this application.

     ·  The information I have provided for this application is complete and  true.

     ·  Misuse of program privileges or misinformation provided on this application may result in a loss of privileges or penalty.

     I acknowledge that I have read and understand the fee assistance application requirements and program terms.

     1. I agree
107. Electronic Signature*
109. Electronic Signature Agreement*

     1. I agree

     By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

Leave This Blank:


111. 1. Receive an email copy of this form.
112. Email address

     This field is not part of the form submission.

113. Submit

* indicates a required field