Client - Self Referral

Client Information

Self Referral
As a Registered Charity, Sport Central’s mandate is to retrieve, repair, recycle and redistribute sports equipment to kids aged 4-17 in families facing financial hardship.

To ensure a quick turnaround for your requested equipment, please complete the information below to the best of your ability.

If you have questions about the information requested below, please call or email us:

780-477-1166 / referrals@sportcentral.org
Family Information
Does your family speak fluent English?

YesNo
If not, please select your primary language:

ArabicUkrainianFrenchMandarin (Chinese)SpanishHindiOther
Please select the below category that best describes your family:

New Canadian ImmigrantRefugeeFirst NationMetisInuitOther
Children's Information:
Please complete the following information for each child. To add more family members, please select "Add Child" below.*
Parent / Guardian's information
First Name*
Last Name*
Mobile*
Please enter a valid phone number.
Other
Please enter a valid phone number.
Email
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Support Documents
Individuals/Families can self-refer using ONE of the following verification methods:

1. City of Edmonton Leisure Access Pass (LAP)

Welcome Letter (with expiry date): Link example

2. Alberta Works Health Benefits Card – Link example
(*not the same as AB Health care Card*)

Letter – Link Example
Proof of HBC (most current month) – Link Example

3. AISH

Proof of HBC (most current month) – Link Example
Please Upload: LAP or Alberta Works Health Benefits Card or AISH

Cancelof
Please upload proof of registration for team sports

Cancelof
Please Note:
• Referrals are only valid for 3 MONTHS after submission.
• Child(ren) must be PRESENT at the time of the appointment.
• If families do not speak English, a third party MUST call and book the appointment.
• Requests that do not include all the information above will not be processed
Next Steps:
Please phone Sport Central after 2 - 4 business days to book an appointment for your family.

780-477-1166

(Monday to Friday 9:00am to 5:00pm)
Terms and Conditions:
As an authorized representative of the above family, I certify that the information on this form is correct to the best of my knowledge. We will comply with the necessary documentation and implementation plan as outlined by Sport Central.
11847 Wayne Gretzky Drive North, NW Edmonton, Alberta T5B 1Y2 780.477.1166 | www.sportcentral.org | referrals@sportcentral.org
Should be Empty:

Client Information

Family Information

Children's Information:

Parent / Guardian's information

Support Documents

Please Note:

Next Steps:

Terms and Conditions: