LEARNER DRIVER APPLICATION FORM

Transcription

1 LEARNER DRIVER APPLICATION FORM Please complete and return to Dion Griffin, L2P Coordinator PO Box 198, Warrnambool, VIC 3280 Fax:

2 WARRNAMBOOL AND MOYNE LEARNER DRIVER APPLICATION FORM The Warrnambool and Moyne L2P Program targets young learner drivers aged years who live in the City of Warrnambool or Moyne Shire and have their learner s permit. It aims to assist young learner drivers who do not have access to either a vehicle or supervising driver to achieve the mandatory 120 hours of driving practice before obtaining a probationary licence Personal Details Surname: First Name: Home Address: City: Post Code: Home Phone Number: Date of Birth: Mobile Phone Number: Age: Sex: MALE / FEMALE Please circle Emergency Contact Name: Home Address: City: Post Code: Home Phone Number: Mobile Phone Number: Relationship to Applicant: Referring service Agency: Contact Person: Contact Details: Phone (Work) Contact Details:

3 Reason for requesting access to the program ( please tick applicable option below): unable to access a suitable fully licensed driver who could provide ongoing driving supervision unable to access a suitable roadworthy vehicle and are experiencing financial disadvantage and/or experiencing homelessness or at risk of homelessness and/or experiencing difficulty gaining a range of driving experiences due to geographic location and/or experiencing other forms of disadvantage that impact on their ability to access to gain the 120 hours Driving Information Current Learners Permit Number: Expiry Date: Number of Professional Lessons: Hours in Log Book: Day: Night: Please indicate your availability for driving sessions, including times: Monday Tuesday Wednesday Thursday Friday Saturday Sunday Reporting and sharing information I give permission for the referring agency to share my information with the L2P Coordinator. I give permission for the L2P Coordinator to share my information with Vic Roads for reporting purposes. Signature Date The personal information in this form is for the purpose of registering you as a Learner Driver with the Warrnambool and Moyne L2P program. The information will be used for this purpose only and will not be disclosed to other organisations without your consent unless required to do so by law. The L2P coordinator will contact the applicant to arrange an informal interview to assess eligibility and discuss program requirements.

4 Photo Consent Form I (name) of (address), give my consent to VicRoads using, reproducing and disclosing photographs or recordings of me and/or my child. VicRoads reserves the right to use any photographs or video/film recordings for its publications, promotional and marketing material, and on its website in order to demonstrate VicRoads programs, products and/or services. This can be for internal or external purposes. If you are signing this consent form on behalf of your child (who has not yet turned 18 years of age), you confirm that you are the parent or legal guardian of the child. VicRoads will keep this consent form on file and a copy will be provided to you. However, you may modify or withdraw your consent in writing at any time and will be effective from the date VicRoads receives such written notification. After notification, VicRoads will not use your image on any further materials produced. Any photographs or video/film may also be used by other government departments and agencies for similar purposes. In signing this consent form, you agree to this possible use. In signing this form I acknowledge that I have read, understand and agree with the contents of this form. Signature Date

5 LEARNER DRIVER CONDUCT AGREEMENT All L2P program learner drivers should understand and agree to work in accordance to the following conduct agreement. Any violation of this agreement may result in exclusion from the program. In choosing to participate in the L2P program I agree to: 1. Follow all program values. 2. Follow all L2P guidelines, procedures and policies as evidenced in the L2P Learner Driver Handbook. 3. Keep all information discussed between myself and the mentor in confidence. 4. Treat all people with dignity and respect. 5. Never be under the influence of alcohol, tobacco, illicit or licit (unless for health reasons) substances while taking part in a driving lesson or other program activities. 6. Not lend money, or give or accept gifts, to or from the mentor. 7. Be reliable, consistent, honest and tolerant of individual differences, values, cultures and viewpoints. 8. Follow the L2P Grievance Procedure to resolve any potential issues 9. Notify the L2P Program Coordinator if I have any changes in contact details. 10. Understand that I may be excluded from the program if I fail to notify the L2P coordinator of changes to driving arrangements on more than three occasions 11. Participate in a closure process when/if required with the mentor. 12. I understand and accept that I may be excluded from the Program in the event of any breach of this agreement that endangers life or property. By signing this Agreement I understand and agree to abide by this code of conduct. Any violation of this agreement may result in your exclusion from the program. I acknowledge and agree to abide by the conduct agreement stated above. Signed: Date:

6 WARRNAMBOOL AND MOYNE L2P LEARNER Driver Criteria Criteria for Access to L2P Program This program is available to young learner drivers who hold a current Victorian Learners Permit but are: unable to access a suitable fully licensed driver who could provide ongoing driving supervision unable to access a suitable roadworthy vehicle and are experiencing financial disadvantage and/or experiencing homelessness or at risk of homelessness and/or experiencing difficulty gaining a range of driving experiences due to geographic location and/or experiencing other forms of disadvantage that impact on their ability to access to gain the 120 hours Learner Driver Referral and Selection Process 1. Local organisations and agencies may refer young people to the program using the accompanying L2P Learner Driver Application Form 2. The number of places available at any given time is dependent on the availability of trained mentors and the capacity of the program. 3. The L2P coordinator will contact the young learner driver to arrange an informal interview to assess eligibility and discuss program requirements. Final selection will be undertaken by a sub- committee of the L2P Steering Committee. 4. The L2P coordinator will aim to match the young learner driver with a suitable mentor according to gender, compatibility, location and availability as opportunities permit 5. The L2P Program reserves the right to determine eligibility of applicants 6. Applicants deemed to be ineligible for the L2P Program will be provided with information about alternative options for gaining driving experience 7. Referrals can be mailed/ faxed/ ed to: Dion Griffin, L2P Coordinator PO Box 198, Warrnambool, VIC 3280 Fax: l2p@warrnambool.vic.gov.au