Driver Licensing Access Program (DLAP) - Expression of Interest -

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Are you..* This field is required.

Individual applicant

Case worker / Parent / Other

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If you are inquiring on behalf of a client or family member you can either:

Select 'Previous' and sitting with the applicant complete the 'individual applicant' form.

or
Complete and submit this form and someone from Youthsafe will contact you to discuss further.

If you have any further questions please contact Lynn Hopgood:

Phone / 0491675485
Email / lynnh@youthsafe.org

Kind regards

The Youthsafe Team

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Name* This field is required.

First Name

Last Name

4

OrganisationIf inquiring from an organisation

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Phone* This field is required.

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Email* This field is required.

example@example.com

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Please provide brief overview of what assistance you are providing

8

Your Name* This field is required.

First Name

Last Name

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Your phone number* This field is required.

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Your email* This field is required.

example@example.com

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Do you identify as* This field is required.

Aboriginal or Torres Strait Islander (ATSI)

Culturally and Linguistically Diverse (CALD)

None of the above

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Are you over 16 years of age?* This field is required.

No

Yes

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Do you have a learner licence?* This field is required.

Yes

No

15

OtherWhat is the suburb of residence?

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Please give us a brief overview of what assistance you need* This field is required.