First Name: / Surname:
Age: / Date of Birth: / /
Postal Address: / Postcode:
Email:
Home Phone Number: / Mobile:
2. Eligibility
Do you currently hold a Victorian Learners Permit? ☐YES / ☐NO (Please Tick)
Permit Number: Expiry Date: / /
Do you have access to a Supervising Driver? ☐YES / ☐NO (Please Tick)
Do you have access to a suitable vehicle? ☐YES / ☐NO (Please Tick)
How many hours of driving experience do you have?Approximately hours
The L2P Program is for Young People with LIMITED or NO access to a supervising driver or vehicle.
What is currently stopping you from gaining driving experience?
Click or tap here to enter text.
3. Other Information
How did you hear about the L2P Program?
Click or tap here to enter text.
Do you currently attend school? ☐ YES / ☐ NO (Please Tick)
Name of School:Choose an item. Other:Click or tap here to enter text. Year Level:Choose an item.
Are you currently employed? ☐YES / ☐ NO (Please Tick) ☐Full Time ☐ Part Time ☐ Casual
Volunteer Supervising Driver Preference: ☐Male / ☐Female / ☐No Preference (Please Tick)
Do you want to get your Manual or Automatic Licence? ☐ Manual / ☐ Automatic (Please Tick)
Please note the Central Grampians L2P Program only has Automatic cars available at this time.
Please indicate which days and times you are available for driving sessions:
☐Monday / ☐Tuesday / ☐Wednesday / ☐Thursday / ☐Friday / ☐Saturday / ☐Sunday
0 to 0 / 0 to 0 / 0 to 0 / 0 to 0 / 0 to 0 / 0 to 0 / 0 to 0
4. Photo Consent
Do you give consent for Central Grampians Local Learning and Employment Network to use your photo for promotional use in regards to the L2P Program?
☐ YES / ☐NO (Please Tick)
5. VicRoads Consent Application Declaration /
If accepted into the Central Grampians L2P Program I hereby consent to the release to VicRoads of my personal information in connection with my participation in the L2P Program.
I agree that VicRoads may hold this information and use it from time to time to administer and evaluate the L2P Program. I also agree that VicRoads may contact me in the future for the conduct of surveys or enquiries relating to the L2P Program.
I declare that the information provided on this form does not include any misleading or false information.
Signature of Applicant______Date: 29/11/2017
6. In Case of Emergency
Please contact:
Name: Click or tap here to enter text. Phone: Click or tap here to enter text.
Relationship to applicant: Click or tap here to enter text.
7. Parent/Guardian Consent. / Only applies to applicants under the age of 18
I consent for my child to be a Learner Driver in the L2P program.
Name Parent/Guardian (Please print clearly):
Signature Parent/Guardian ______Date: 29/11/2017
8. Referral (for referring agency only) / To be contacted by L2P Coordinator when application is submitted
Agency Name:
Contact Person: Phone Number:
Email Address: /
Code of Conduct
All L2P Program Learner Drivers should understand and agree to behave in accordance to the following code of conduct. Any violation of this contract may result in their immediate exit from the program.
In choosing to participate in the L2P program, I agree to:
Respect the privacy of the Mentor and treat everyone with respect.
Attend driving sessions at the agreed time and place. If you need to cancel, you must notify the Mentor and L2P Coordinator at least 24 hours prior.
Be clean, tidy and wearing appropriate footwear during all driving sessions (bare feet, thongs, ugg boots and heels are not appropriate).
Logbooks must be completed for each driving session. NO LOGBOOK, NO DRIVE.
When requested, logbooks are to be given to the L2P Coordinator to collect VicRoads Reporting data.
Inform the L2P Coordinator of any medical condition or medication that may impair your ability to drive.
Never consume or be under the influence of drugs and/or alcohol while participating in the L2P Program. The blood alcohol content for everyone in the L2P Program is .00, coming to a driving session under the influence of drugs and/or alcohol will result in immediate exit from the program.
No smoking in the L2P car.
All mobile phones and electronic devices are to be turned off during driving sessions.
When in control of the L2P car the Learner is responsible for any traffic offences such as speeding fines or parking tickets. If a traffic offence is incurred, please notify the Coordinator ASAP.
An incident report is to be completed and given to the Coordinator for all accidents no matter how big or small.
Maintain regular contact with the L2P Coordinator, let us know if you get a new phone number, address or job and respond to all calls or messages quickly.
If you have any questions or concerns about the program contact the Coordinator directly.
If you break the Code of Conduct:
The Central Grampians L2P Program has a 3-strike policy.
If you receive a strike you will be notified in writing. The Coordinator and Learner will discuss the problem and decide how to move forward.
Depending on the severity of the problem and the number of strikes previously given, the Learner may be suspended or removed from the program.
If you are unhappy with the decision made by the L2P Coordinator, you have the right to dispute the decision through the formal grievance procedure. (see the Learner Driver Guidelines for more information)
I______acknowledge and agree to abide by the Code of Conduct stated above.
Signed: ______Dated: 29/11/2017