Drive to Thrive: Program Application for Participant

Drive to Thrive: Program Application for Participant
YOUTH INFORMATION
Name:
Date of Birth:

MeseGiornoAnno
Data
Current Age:
Address:
Phone:
Format: (000) 000-0000.
Email: (Youth's personal email address)
esempio@esempio.com
Client ID
Case Manager Name:
Case Manager Agency/County:
Independent Living Case Manager/Other Case Manager:
Case Manager's Contact (E-Mail or Phone Number)
CAREGIVER INFORMATION
Name:
Address:
Phone:
Format: (000) 000-0000.
Email:
esempio@esempio.com
GUARDIAN AD LITEM INFORMATION
Name:
Phone:
Format: (000) 000-0000.
Email:
esempio@esempio.com
WHICH MILESTONES HAVE YOU COMPLETED?
(Please attach supporting documentation)
File Upload

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Your application will be processed within 15 business days. By submitting this application, you agree that you've read the program eligibility requirements.
PARTICIPANT ROLES & RESPONSIBILITIES
Attention Caregivers
Utilize this form for discussions when considering the readiness of any youth who desires to obtain a Learner's License or Driver's License.
YOUTH INFORMATION
Name:
Date of Birth:

MeseGiornoAnno
Data
Current Age:
Address:
Phone:
Format: (000) 000-0000.
Other Contact Information:
Current Placement Type
Other:
Special Needs/Accommodations
Youth Responsibilities
I.
Full Name
, understand that to participate in the Virginia Drive to Thrive Program I have certain responsibilities that will be placed upon me for full participation and reimbursement.
I understand that:
My participation is voluntary.
Participation and reimbursement for eligible expenses is subject to monitoring and review.
I will abide by all Virginia laws and DMV requirements while I am learning to drive.
I agree to abide by all Virginia safe driving laws and practices including:
Following posted speed limits
Using seat belts
Not using my cell phone for calling or texting while driving
I agree to not operate a motor vehicle unless I am insured and have permission to drive the vehicle.
If I receive a ticket for a moving violation or an at-fault accident, I will inform my caregiver immediately, cease driving, and comply with all DMV regulations.
If I am requesting reimbursement for any eligible expenses, I must complete a Reimbursement Request form along with my caregiver and provide all related documentation.
Caregiver Responsibilities
I.
Full Name
, understand that to participate in the Virginia Drive to Thrive Program I have certain responsibilities that will be placed upon me for full participation and reimbursement.
I understand that:
My participation is voluntary.
Participation and reimbursement is subject to review and monitoring.
I will ensure that the youth abides by all Virginia laws and DMV requirements while learning to drive, including when they have their Learner's License and Intermediate License.
I agree to encourage the youth to abide by all Virginia safe driving laws and practices including:
Following posted speed limits
Using seat belts
Not using a cell phone for calling or texting while driving
I agree to not allow a youth to drive a car without insurance.
If the youth receives a ticket for a moving violation or an at-fault accident, I will enforce all DMV regulations regarding revocation, suspension, or restriction of their license.
If I am requesting reimbursement for any eligible expenses, I must fill out a Reimbursement Request along with the youth and provide all related documentation.
Signature of Youth:
Date:

MeseGiornoAnno
Signature of Caregiver:
Date:

MeseGiornoAnno
OFFICE USE ONLY
Date Received Staff:

MeseGiornoAnno
Status
Should be Empty:

Drive to Thrive: Program Application for Participant

YOUTH INFORMATION

CAREGIVER INFORMATION

GUARDIAN AD LITEM INFORMATION

WHICH MILESTONES HAVE YOU COMPLETED?

PARTICIPANT ROLES & RESPONSIBILITIES

YOUTH INFORMATION

Youth Responsibilities

Caregiver Responsibilities

OFFICE USE ONLY