Referral Form | Driving Equality

Application Introduction

At Driving Equality we are aware of the many ways that driving can transform lives. Unfortunately, the demand for our Community Lessons Programme greatly exceeds availability. Consequently, we have created the following form to enable us to fairly assess our applicants and to determine those who would benefit most from receiving these lessons.

Please ensure you answer all of the questions as openly and honestly as possible to give us the best possible insight into the applicant's circumstances. If you wish to see a plain-text version of this form for reference purposes, please Click Here.

Section 1: Referrer Information

Please provide the following information about the referrer:

What is your full name?

What organisation do you belong to?

What is your primary email you wish to be contacted via?

What is your primary phone number you wish to be contacted via?

Section 2: Applicant Information

Please provide the following information about the applicant:

What is the full name of the applicant?

What is the age of the applicant?

What is the applicant's postcode?

Does the applicant qualify for a Motability Driving Lessons Grant? For more info Click Here Yes No

Will the applicant be able to contribute to the cost of lessons? Yes No

If yes, please state how are they able to contribute: Per Hour Per Week A One-Off Payment

If yes, please provide an indication of the amount they are able to contribute:

Section 4: Driving Experience

Please provide the following information about the applicant's previous driving experience:

Does the applicant have a valid UK provisional driving licence? Yes No

Does the applicant have a valid theory test certificate? Yes No

If yes, please provide the certificate expiry date:

Does the applicant have a practical test booked? Yes No

If yes, where is the location?

If yes, what is the date?

If yes, what is the time?

Does the applicant have any previous driving experience? Yes No

If yes, please state their experience.

What is the applicant’s availability for lessons?

Section 5: Impact & Influence

Please provide the following information about how driving lessons will benefit the applicant’s life:

Please select the areas in which the Applicant will be positively impacted by receiving driving lessons: Education Work Mental Health Financial Situation Caring Responsibilities Other...

From the selected areas above, please state how the applicant will benefit:

Will driving lessons benefit others in addition to the applicant? Yes No

If yes, please state who will benefit:

If yes, please state how they will benefit:

Section 6: Declaration

I agree to the Driving Equality CIC. Terms of Service

I agree to Driving Equality CIC. accessing and processing the data submitted in this form to assess and respond to this application on behalf of myself, the referrer, for the benefit of the applicant.

I agree that I, the referrer, am responsible for the data submitted in this form on behalf of the applicant and have permission to share this with Driving Equality CIC.

I accept that Driving Equality CIC. will store the data submitted on this form for a period of 12 months for future consideration.

I accept that Driving Equality CIC. may be required to reach out to me via my provided contact methods to request additional information or evidence to support this application.

Referral Application Form