Drive to Thrive: Placement Update Form

Drive to Thrive: Placement Update Form
Attention Youth and Caregivers
Anytime a youth moves placements, a Case Manager must be contacted. If a youth moves to a different out-of-home placement, they are still eligible for the program but must submit a new Participant Roles & Responsibilities Agreement signed with the appropriate caregiver.
Questions should be directed to Case Manager.
YOUTH INFORMATION
Name:
Date of Birth:

MonthDayYear
Date
Current Age:
Address:
Phone:
Format: (000) 000-0000.
Email:
example@example.com
Current Placement Type

Other:
Client ID:
Case Manager Name:
Case Management Agency/County:
CAREGIVER INFORMATION
Name:
Address:
Phone:
Format: (000) 000-0000.
Email:
example@example.com
Relationship to Youth:
PARTICIPANT ROLES & RESPONSIBILITIES
Youth Responsibilities
I,
, understand that participation in the Virginia
Drive to Thrive Program includes the following responsibilities:
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 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 insured and permitted to drive.

If I receive a ticket for a moving violation or an at-fault accident, I will inform my caregiver immediately.

If requesting reimbursement, I must complete all required forms and provide supporting documentation.
Caregiver Responsibilities
I,
, understand that participation in the Virginia
Drive to Thrive includes the following responsibilities:
My participation is voluntary.

Participation and reimbursement is subject to review and monitoring.

I will ensure the youth abides by all Virginia laws and DMV requirements.

I agree to encourage 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 without insurance.
If the youth receives a moving violation or at-fault accident, I will enforce all DMV regulations.
I will complete reimbursement forms and provide all related documentation.
YOUTH AND CAREGIVER CERTIFICATION
By signing below, we certify that:
Both applicant youth and caregiver have read and understand the application packet.
Both applicant youth and caregiver understand that youth must complete a driver's education course to be reimbursed for costs associated with auto insurance.
Should a placement change occur after enrollment, the Case Manager must be contacted immediately.
Should the youth's license be revoked, suspended, or restricted, the Case Manager must be contacted immediately.
Signature of Youth:
Date:

MonthDayYear
Signature of Caregiver:
Date:

MonthDayYear
Should be Empty:

Drive to Thrive: Placement Update Form

YOUTH INFORMATION

CAREGIVER INFORMATION

PARTICIPANT ROLES & RESPONSIBILITIES

YOUTH AND CAREGIVER CERTIFICATION