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2. The Grade 5 Get Active! pass is good for unlimited free admissions and the Grade 6 Stay Active! pass is good for a total of 12 free admissions to either drop-in swimming, skating and gymnasium-based activities in the cities of Coquitlam, Port Moody and Port Coquitlam.

4. Applicant Information

6. Child’s First Name*
7. Child’s Last Name*
9. Address*
10. City*
11. Postal Code*
13. Date of Birth*
14. What Grade will child be in Sept 2023 – June 2024 school year?*
16. Name of School*
17. City of School*

21. Parent/Guardian Information

23. Parent/Guardian Name*
24. Relationship to Participant*
26. Guardian Phone Number*
27. Guardian Email*
28. Guardian Date of Birth*

32. Documentation

    Once membership has been added to child’s account, go to either:  Poirier Sport and Leisure Complex, City Centre Aquatic Complex, or the Pinetree Community Centre to have picture taken and card printed.

    Please Scan and upload the Following Documentation.

34. Proof of Coquitlam Residency*

    Proof of Coquitlam residency  e.g. phone, hydro, cable or gas bill or a property tax notice. Post office boxes are not acceptable.

38. Pass Terms

    1. Passes must be presented to the cashier at the time of admission. Students without their passes will have to pay regular admission rates.
    2. Remember to keep your cards safe. Replacement cards are available at a nominal fee of $5.
    3. The passes are non-transferable and use of the card by anyone other than the registered cardholder will result in loss of the card and the privileges associated with it.
40. Freedom of Information and Protection of Privacy Act*

    1. I understand

    I understand by submitting this form I am consenting to the collection, use, and disclosure of my personal information for the purposes of the Grade 5/6 Get Active Program in accordance with the Freedom of Information and Protection of Privacy Act, (the “Act”). That my personal information will be disclosed to a third-party service provider (i.e. Civic Plus and PerfectMind) located in Canada for the purpose of processing my application. That if I have questions about the collection of my information I can contact Jamie Ayson-Banico - City of Coquitlam, Parks Recreation and Culture, at 604-927-6944.

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42. 1. Receive an email copy of this form.
43. Email address

    This field is not part of the form submission.

44. Submit

* indicates a required field