LEARNER DRIVER EXPRESSION OF INTEREST FORM

Personal Details
Surname / First Name
Address
Email / Phone
Date of Birth / Gender
Country of Birth
Australia
Viet Nam
Malta
Philippines
Italy
Former Yugoslav Republic of Macedonia
Croatia
India
United Kingdom
Greece
Other (please specify) / Preferred Language
English
Vietnamese
Maltese
Italian
Greek
Macedonian
Croatian
Cantonese
Filipino (Tagalog)
Arabic
Other (please specify)
Are you of Aboriginal or Torres Strait Islander descent?
No
Yes, Aboriginal
Yes, Torres Strait Islander
Other Information
Current Learners Permit Number / Expiry Date
Are you currently (circle)
  • Working
  • At School
  • Other (please specify) ______

Mentor Preference(circle)MaleFemaleEither
How did you find out about the L2P program?
Do you have a preferred region of Brimbank within which to meet for driving sessions? (circle)
SunshineKeilor DownsNo Preference
Why do you want to join the L2P Program?
Do you have driving experience already?
Who supervised your previous driving experience? Why are they no longer available?
What days & times are you available for driving sessions?
Mon / Tue / Wed / Thu / Fri / Sat / Sun
Please provide details of two professional and/or community based references. These people will be contacted to provide a character references (please note, referees must have known you for at least 12 months and must not be family members or friends)
Name / Organisation / Position / Relationship / Phone / Email

Thank you for your interest in the L2P program.We will be in contact with you as soon as the program resumes accepting new referrals. We really appreciate your patience.

Please return this completed form to:

L2P Program Officer

Youth Services

PO Box 70

Sunshine VIC 3020

Personal and/or Health information collected by Council is used for municipal purposes as specified in the Local Government Act 1989. The Personal and/or Health information will be used solely by Council for these purposes and/or directly related purposes. Council may disclose this information to other organisations if required by legislation. The applicant understands that the Personal and/or Health information provided is for the above purpose, and he or she may apply to Council for access to and/or amendment of the information. Requests for access and/or correction should be made to Council’s Privacy Officer.

Referees Details
Name of Agency:
Contact Name:
Position:
Contact Telephone:
Email Address:
Reason for Referral:
Please describe the young person’s motivation and attitude for driving:

Thank you for your interest in the L2P program. We will be in contact with you as soon as the program resumes accepting new referrals. We really appreciate your patience.

Please return this completed form to:

L2P Program Officer

Youth Services

PO Box 70

Sunshine VIC 3020

Personal and/or Health information collected by Council is used for municipal purposes as specified in the Local Government Act 1989. The Personal and/or Health information will be used solely by Council for these purposes and/or directly related purposes. Council may disclose this information to other organisations if required by legislation. The applicant understands that the Personal and/or Health information provided is for the above purpose, and he or she may apply to Council for access to and/or amendment of the information. Requests for access and/or correction should be made to Council’s Privacy Officer