Leisure Access Program Referral Agency Application

Client(s) and Additional Household Family Members

Full NameDate of BirthOperations
Use the button above to add additional family members

Client Information

Primary Client Info

Referral Agency Use

# In Household123456
Income Under$27,252$38,682$47,375$54,704$61,161$66,998


The personal information on this form is collected by the City of Prince George for the purpose of registration in the Leisure Access Program and communication about the program, under the authority of section 26(c) of the Freedom of Information and Protection of Privacy Act. If you have any questions about the collection of information, please contact the Manager, Aquatics or Supervisor, Civic Initiatives and Partnerships at 1100 Patricia Boulevard, Prince George, BC, by telephone (250-561-7600 or 311), or email leisureaccessprogram@princegeorge.ca.