Life Drive

Application Form

Title (Mr etc):
First name:
Surname:
Address:
Mobile:
Email address:
DoB:
Date driving test passed:
How did you hear about Life Drive? / Friend/relative who attended the course previously
ADI / Local Authority website
Dorset Alert / SafeWise Website
Facebook / Twitter
BH Life / Practical Driver Guide
Bournemouth Echo / Daily Echo
School/University (which school?)
Other (please say)
Please select which Life Drive course date you would like to attend - Thurs 07/12/17, Tues 09/01/18, Thurs 18/01/18 (Weymouth), Thurs 22/02/18 and Tues 20/03/18.
Please can you provide a valid Driving License No and National Insurance No. Instructors will check licences online prior to each drive out. / Driving License No. / National Insurance No.
Would you like to take part in a 60 minute evaluation drive out in around 6 months’ time?
Date Sign


Please complete, date, sign (electronic is acceptable) and return this form to Helen Bromley:
Helen Bromley, Bournemouth Centre Co-ordinator & Finance Support, SafeWise Bournemouth … Email

Post: SafeWise Bournemouth, Unit 1 Roundways, Elliott Road, Bournemouth BH11 8JJ

HOW IT WORKS:
1 Complete the Pre-Course Questionnaire prior to your course. This will be emailed to you when

once you have confirmed your course date.
2 An Approved Driving Instructor will then contact you for your one-to-one 90 minute drive out
3 Complete the online Post Course Questionnaire and …
4 ….wait for your £50s worth of 'thank you' Amazon vouchers to be emailed.
5 You may also be randomly invited to book in for a further FREE one-to-one 60 minute drive outwith an ADIin six

months' time to help us evaluate the success of the scheme.

SafeWise complies with the Data Protection Act 1998. The personal information you provide to us will be kept confidential and will used only in conjunction with the Life Drive initiative. SafeWise will store the information given on this form and any additional information given to us securely and will retain it in line with our Data Protection Policy.

SafeWise Bournemouth & SafeWise Weymouth are part of the SafeWise charity Reg no 1058562

30.11.17