EmailMe Form - LEARNER DRIVER APPLICATION FORM

Name

First Last

Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country

Phone (BH)

Phone (AH)

Mobile

Email address

Date of Birth

DD / MM / YYYY

Sex

Male

Female

Licence Number

Expiry Date

DD / MM / YYYY

EMERGENCY CONTACT DETAILS

Please supply details for 2 emergency contacts. These should be responsible adults who, for example, can assist you to travel if necessary

Name

First Last

Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country

Phone (BH)

Phone (AH)

Mobile

Name

First Last

Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country

Phone (BH)

Phone (AH)

Mobile

Do you have any medical conditions, allergies, disabilities or past injuries that may affect your participation

Yes

No

MANAGEMENT PLAN FOR PRE-EXISTING INJURY/CONDITION

What is the medical condition

Allergy

Disability

Past injury

Other

Please provide details

INFORMATION ABOUT THE CONDITION/INJURY

How serious is the condition if aggravated
(Tick one or more boxes)

Potentially life threatening

Could require own mediction

Could require rest or time off work

Could require medical (doctor, hospital) treatment

In your own words tell us how we recognise that your condition has recurred or been aggravated

What actions, tirggers or situations do you need to avoid

What is the management plan to minimise any aggravation to the condition/injury

E.g. Self medication, avoidance of allergy triggers (specify) etc

What is the emergency plan if serious aggravation does occur

CONDITIONS OF PARTICIPATION

I have notified the Project Manager of any relevant medical conditions and pre-existing injuries, and I consent to the Project Manager rendering or authorising such medical treatment as necessary and accept responsibility for all associated expenses

I am a participant in the LEAP (Learner Education Assistance Program)

I will not smoke, consume or store alcohol or illicit drugs while participationg in the program

I shall respect the rights, feeling and property of all others associated with LEAP

I shall cooperate with the Project Manager and Volunteers to ensure a safe, happy and hygienic team environment

My placement in the project is at the discretion of the Project Manager

Photographs or videos taken of me on a project may be used by the Committee for promotional purposes

Yes

No

I understand that the payment for the program must be paid in full prior to commencing the program, and this is non-refundable

I will notify the Project Managerat least 24 hours before the start of my session if I am unable to attend

I will give the Project Manager one weeks' notice if I decide to withdraw from the program

I agree to ensure that I keep my mileage account in credit

I agree to comply with the above terms that refer to my participation in all projects and activities

Agree