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Apply for support with Driving Lessons
GENERAL INFORMATION
Full Name
First name
Last name
Other Known Names
What Name Would You Prefer?
Date of Birth
Ethnicity (Choose One)
Maori
Pasifika
Asian
European
Indian
Other
Gender
Female
Male
Non-Binary
Other
Prefer not to Say
Address
Are you on a benefit?
Yes
No
Is this an MSD Referral?
If so please advise your MSD number:
HOW CAN WE CONTACT YOU?
Home phone
Mobile Phone
Email address
*
Do you have a learners driver’s license?
No
Yes
Do you have experience driving in small towns e.g. Te Puke, Whakatane, etc?
Less than 20hrs
Less than 30hrs
more than 40hrs
You would be required to have additional driving lessons with family or friends. Do you have the supported to do so?
Yes
No
Comments
Do you have a medical condition, illness or injury that could affect your driving?
Yes
No
If yes, please comment
Are you availabe on Tuesday's between 10:30am-1:30pm?
Yes
No
There is a small fee of $30 per lesson, payable in advance of your lesson. Do you you want to proceed with your application?
Yes
No
Someone will contact you to discuss your application and set up a time to meet. Any questions contact the Coordinator via text/call - 0273209072 or email cld@colabcommunity.nz
Group
Drive to Thrive
Submit
Please check the highlighted fields
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