Lacombe & District - Family and Community Support Services

1. Parent/Guardian Name (First/Last) *

2. Parent/Guardian Name (First/Last)

Date *

Phone

Email

Preferred Contact Method *

Text

Phone

Email

Address *

City *

Postal Code *

Have you lived in the City of Lacombe or the Lacombe Rural District for more that 6 months? *

Yes

No

Are you a City of Lacombe resident *

Yes

No

Are you a Lacombe County resident *

Yes

No

Child #1 - Name (First/Last) *

Child #1 - Age *

Child #1 - Grade *

Child #2 - Name (First/Last)

Child #2 - Age

Child #2 - Grade

Child #3 - Name (First/Last)

Child #3 - Age

Child #3 - Grade

1. Parent / Guardian Notice of Tax Assessment: *

2. Parent / Guardian Notice of Tax Assessment:

I confirm that the information provided on this application is true and correct and that I have not concealed or omitted other pertinent information regarding my income or financial supports. *

Yes

I understand that the assistance received through this program is ONLY to purchase winter wear for the children listed above. No merchandise purchased can be returned for refund. *

Yes

I understand that Coats for Kids assistance can only be provided once every two years per child. *

Yes

I have not applied for or received winter wear assistance through any other agency. *

Yes

I understand that FCSS may review the information provided on this application and that failing to provide true and accurate information may disqualify me and my family from receiving assistance at this point and in the future. *

Yes

2022 Coats for Kids Program

Note: