LIFE Program Application 2024

Full Name (Primary Applicant)

Mailing Address (including postal code) - MUST be a resident of Esquimalt

Address

Address 2

City/Town

Province

Postal Code

Phone Number

Email Address

Birthdate

List Additional Household Members / Dependants (Names and Birthdates)

Please list all members of your household, including all dependant children (0-18 years) and a spouse/partner (if applicable). Please follow the following format: Firstname_Lastname mm-dd-yyyy; IE; Jane_Doe 01-05-1962 Please note: in common-law and martial situations, combined income is required for application. Therefore: both individuals will need to provide proof of income by showing individual notice of assessments.

Final Submission

Pass Option

OPTION A: 52 Free Admissions to Drop-in Sessions at any Greater Victoria Recreation Centre For use at Esquimalt, Saanich, City of Victoria, Oak Bay, Panorama, West Shore and SEAPARC. > Your L.I.F.E. card must be presented at the time of admission. > One card is issued once per year for each household member.
OPTION B: 52 Free Admissions to Drop-in Sessions at Esquimalt Recreation Centre ONLY (electronically added to Esquimalt's system)
OPTION C: 50% off annual Esquimalt only pass (total after discount: adult: $192.50, senior: $146.50, youth $100, child $80 > electronically added to Esquimalt's system)
OPTION D: 50% off Regional Recreation pass (total after discount: $276 > electronically added to Esquimalt's system, physical card needed to access all other centres)

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Personal information contained in this form is collected under Section 26 (c) of the Freedom of Information and Protection of Privacy Act and will only be used for the form’s stated purpose. If you have any questions about the collection or use of your personal information, please contact the Corporate Officer at corporate.services@esquimalt.ca or 250-414-7135. More information can be found through our privacy policy.