Please ensure you have read the application guidelines completely before submitting this form to ensure your request is processed as quickly as possible.
*
Denotes a Required Field
Applicant Contact Information
(the individual who will benefit from the request)
*
Last Name
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Given Name
*
Date of Birth
Day
1
2
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31
Mth
Jan
Feb
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Aug
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Year
2010
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1991
1990
1989
Address
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City
Postal Code
Province
Prov
BC
AB
MB
NB
NL
NT
NS
NU
ON
PE
QC
SK
YT
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Telephone
Mobile
Email
Guardian Contact Information
*
Last Name
*
Given Name
Address
City
Postal Code
Province
Prov
BC
AB
MB
NB
NL
NT
NS
NU
ON
PE
QC
SK
YT
*
Telephone
Mobile
Email
Sponsor Contact Information
Last Name
Given Name
Address
City
Postal Code
Province
Prov
BC
AB
MB
NB
NL
NT
NS
NU
ON
PE
QC
SK
YT
Telephone
Mobile
Relationship to applicant:
Please select one
Physician
Nurse
Relative
Friend
Community Organisation Member
RCMP Member
Other
Social Worker
Please provide a short description of the potential recipients illness or injury
Please provide a short personal history of the potential recipient
Grant Request Details
Please describe the specific purpose for the use of the funds:
Amount Requested
Living Expenses
Capital Purchase
Have you, or will you be, receiving funding or support from other charitable organisations?
No
Yes
If so, what is the actual or anticipated amount of the other support?
Trust Fund Information
Do you have a trust fund established?
Yes
No
If no, do you plan on establishing one?
No
Yes
Supporting Financial Institution Information
Name of Institution
Trust A/C Number
Contact Name
Telephone
Address
City
Province
Prov
BC
AB
MB
NB
NL
NT
NS
NU
ON
PE
QC
SK
YT
Postal Code
Email address
Trustee Information (1)
Last Name
Given Name
Address
City
Postal Code
Province
Prov
BC
AB
MB
NB
NL
NT
NS
NU
ON
PE
QC
SK
YT
Telephone
Mobile
Email
Trustee Information (2)
Last Name
Given Name
Address
City
Postal Code
Province
Prov
BC
AB
MB
NB
NL
NT
NS
NU
ON
PE
QC
SK
YT
Telephone
Mobile
Email
Survey and Declaration
How did you hear about Cops for Kids?
Please select one
Family Member
Friend
Health Care Professional
Other Recipient
Community Organisation Member
RCMP Member
Other
If other, please explain
Use of Personal Information
Cops for Kids relies on free public relations stories to encourage donations and to let people know we may be able to help them Your story could help us to help others.
Would you agree to being presented Cops for Kids funding in a public setting such as a news conference?
Yes
No
Would you agree to have your story (including photos) posted on the Cops for Kids website and used in press releases?
Yes
No
If you would like to define limitations on how your story could be used by Cops for Kids, please detail here:
Declaration
By submitting this form, I declare that all the information provided in the application is true and complete, and that any funds awarded will be used for the purpose(s) specified in the application or those funds will be returned to the Cops for Kids Charitable Foundation.
The submission of this form also indicates the applicant is aware of the requirements of the Cops for Kids Charitable Foundation and that if any funds are awarded, the applicant agrees to abide by those requirements.
I declare that the information in this application is true and complete. I certify that if funds are awarded they will be used for the purposes described in this application.
Re-entering your name and email address in the following boxes constitutes your signature.
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Name
*
Email