Required fields are marked with an asterisk (*).

Your details

Name of learner *

Date of birth *

Age *

Gender

Contact phone *

Email address *

Address

Do you have a learner driver's licence? *

• Yes
• No

Learner licence number

Learner licence expiry date

How did you hear about the Y drive program? *

• Referral
• Social media
• School
• Radio
• Other

Are you on any type of medication? *

• Yes
• No

Language spoken at home? *

Do you wear glasses for driving? *

• Yes
• No

Do you identify as Aboriginal/Torres Strait Islander? *

• Yes
• No

Do you have a disability / injury / mental health issue? *

• Yes
• No

If yes, could it affect your ability to drive?

• Yes
• No

Referral / support agency and name of agent:

What assistance do you require to get your learner licence?

Have you had any experience driving a vehicle before? *

• Yes
• No

Tell us a little about your driving experience *

How many hours do you currently have in your log book?

Do you have any traffic fines or have you been disqualified from driving? *

• Yes
• No

Have you had any professional driving lessons before? *

• Yes
• No

Why do you need to be on the Ydrive Program? *