Learner Driver Hours Application Form

Learner Driver Hours Application Form
Full Name*

First NameLast Name
Email Address
example@example.com
Phone Number*
Date of Birth*

DayMonthYear
Address*

Street Address

Street Address 2

CityState / Province

Postal / Zip Code
Learner Permit Number*
Date of learner permit expiry*

DayMonthYear
Date
Leaner Permit Conditions (if applicable)
What day(s) (Mon-Thurs) would you be available for mentoring? *
Would you like to learn auto or manual?*
Gender*

FemaleMaleOther / prefer not to say
Preferred pronouns*

She/herHe/himThey/themOther / prefer not to say
Are you of Aboriginal or Torres Strait islander descent?*

None of the aboveYes, AboriginalYes, Torres Strait IslanderYes, both
Do you speak any other language(s) beside English? If yes, which language(s)?
Learner Driver's Medicare card number: *
How did you find out about our mentoring program?*

SchoolCommunity organisationWord of MouthSocial mediaCNC / Youth teamOther
Do you have any prior driving experience?*

YesNo
If yes, how many hours are recorded in your log book?
Are you currently suffering from any serious (permanent or long term) illness, disability, medical condition, or injury (or the effects of treatment for any of those things) that may affect your fitness to drive?*
Is there anything else that may impact your participation in the program?*
Do you have any further questions, enquiries or comments you'd like to ask?
I understand and agree that:*
Todays Date*

DayMonthYear
Your Signature:*

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If under 18; Parent/Guardian consent is also required:
I give permission for (child's name) Enter here to participate in this program.
Parent/Guardian details:
Parent/Guardian Signature:

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Should be Empty: