Leisure Access Program Application

The Leisure Access Program grants annual access for the applicant(s) to attend drop-in programs offered at the Cowichan Aquatic Centre and Fuller Lake Arena. The program is available to residents of the Municipality of North Cowichan, Cowichan Valley Regional District, City of Duncan, Cowichan Tribes Reserve Lands, and the Town of Ladysmith.

Eligibility requirements:
The Leisure Access Program is specifically designed for economically disadvantaged residents who live within the boundaries of the geographical areas listed above. In order to qualify for this program, individuals or families must provide proof of residency and income verification.

Total gross household income is the total combined income, before taxes, received by all members of the household. Line 15000 on your 2024 Notice of Tax Assessment.
Total income cutoffs - 2025 Leisure Access Program
Number of people in household	1	2	3	4	5	6	7+
Gross household income	$26,759	$33,312	$40,953	$49,724	$56,395	$63,605	$70,815

Personal information is collected by the Municipality of North Cowichan under the authority of s.26(c) of the Freedom of Information and Protection of Privacy Act for the purposes of processing application requests. Should you have any questions about the collection of this personal information, please contact Information Management Officer, (250 746-3116; 7030 Trans-Canada Highway, North Cowichan, BC V9L 6A1.

How will you be verifying your income?

Name of applicant

First name

Last name

Residential address

Street number and name

City/Town

Province

Postal Code

Date of birth

Phone number (daytime)

Email address

List each person living in your household:

Each person living in your household MUST be listed below. Add additional rows, as needed.

Re-order	Last name	First name & middle initial	Date of birth	Weight	Operations
	Last name	First name & middle initial	Date of birth	Item weight

more items

Proof of residency

Provide a copy of a current and valid government-issued photo ID for each applicant over the age of 18 in the household. The address on the ID must match the address provided in the application.

Unlimited number of files can be uploaded to this field.
64 MB limit.
Allowed types: gif, jpg, png, bmp, eps, tif, pict, psd, txt, rtf, html, odf, pdf, doc, docx, ppt, pptx, xls, xlsx, xml, avi, mov, mp3, ogg, wav, bz2, dmg, gz, jar, rar, sit, svg, tar, zip.

Income verification - Notice of Assessment

Provide a copy of your 2024 Notice of Assessment from Revenue Canada

One file only.
64 MB limit.
Allowed types: gif, jpg, png, bmp, eps, tif, pict, psd, txt, rtf, html, odf, pdf, doc, docx, ppt, pptx, xls, xlsx, xml, avi, mov, mp3, ogg, wav, bz2, dmg, gz, jar, rar, sit, svg, tar, zip.

Income verification - Referral

This section is to be completed by applicants who are verifying their income by referral from the Ministry for Children and Family Development, Ministry of Housing and Social Development, Community Living BC, or the Cowichan Tribes Social Development and Community Safety Department.

This section must be completed by a representative of one of the agencies listed above.

Please verify the following:

Name of applicant

Number of family members living in the household

I verify that the above information is accurate, and that this applicant has a household income within the allowable limits outlined at the top of this application form.

Office address

Please provide the address of the referral agency.

Upload a photo or copy of your professional stamp or business card

Date signed

By submitting this application, I DECLARE AND AFFIRM:

that all the information provided with this application is true, correct, and complete to the best of my knowledge; and
that all information provided verbally or in writing in relation to this application will be held in strict confidence by the Municipality of North Cowichan; and
that Leisure Access Passes may be cancelled for failure to observe facility rules, including violations of North Cowichan's Code of Conduct and Respectful Spaces Bylaw.