Keys4Life Referral Form

Keys4Life is a pre-driver education program that allows people aged 15 – 24 years of age to learn about safe driving and sit their Learner’s Permit Theory Test. The aim of the training is to develop positive road user attitudes and to help individuals make safer, informed decisions in traffic and social situations.

If you have any questions and queries about completing this form, please reach out to:

Nicole McRostie - Youth Case Worker

Email: Nicole.McRostie@risenetwork.com.au

Phone: 0461 271 253

Applicant Details

Legal Name *

Preferred Name

Date of Birth *

Contact Number: *

Email Address *

Address *

Street address *Street address line 2 *

State *

Postcode *

Emergency Contact Details

Name *

Relationship *

Emergency Contact Number *

Support Agency Details

Name of Agency

Support Worker Name

Agency/Support Worker Contact Number

Do you suffer from any learning difficulties that may require a support person? *

Do you have any medical/physical conditions, or other issues, which may impact on your participation/accessibility of training and/or adjustments to be made to the environment? *

If you answered 'Yes' above, you will be required to bring a support person to assist you.

RISE will provide light refreshments for training. Do you have any dietary requirements? *

If you answered 'Yes' to the question above. Please advise us of your dietary requirements below:

Do you consent to photos being taken during training? *

I understand and commit to the following with the support of my Keys4Life facilitators:

(Please tick all three options):

Attendance must be 80% or greater to sit the theory test at the end of training.

*

A score of 24 or more must be achieved to pass the theory test. *

Two attempts at the theory test can be given. *

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