Ignite Drive Academy Registration – Single Driving Lesson - Maca Sports Leadership Charitable Trust

Register for Ignite Drive Academy

Single Driving Lesson – $90.

Complete the form below to be redirected to payment.

Personal Details (please fill out details exactly how they are on licence)

First Name

Last Name

Address

Date of Birth

Age (15 – 24 years only)

Email Address

Phone Number

Emergency & Medical Information

Doctor / Medical Centre Name

Doctor Phone Number

Emergency Contact Name

Emergency Contact Phone Number

Please outline any health concerns, medical conditions, injuries, medications, or learning needs we should be aware of

Driver Licence Information

Driver Licence Number

Licence Version Number

Date Licence Issued (found on back of licence)

Driving Experience

How much driving experience have you had?

Do you experience anxiety or nervousness when driving?

Yes No

If yes, please explain

Self-Assessment of Driving Ability

Please select the number that best reflects your current driving ability (1 - Beginner => 10 - Excellent Driver)

Participant Declaration

I confirm that the information provided in this form is true and correct to the best of my knowledge. I understand that this information is collected for the purpose of safely supporting my participation in the Ignite Drive programme.

I acknowledge that I have read and agree to the Commitment Terms

Date

Privacy Statement

All personal information collected will be kept confidential and managed in accordance with the Privacy Act 2020. Information will only be used for programme delivery, health and safety, and participant support purposes.

Register for Ignite Drive Academy

Personal Details (please fill out details exactly how they are on licence)

Emergency & Medical Information

Driver Licence Information

Driving Experience

Self-Assessment of Driving Ability

Participant Declaration

Privacy Statement

MACA Sports Leadership Charitable Trust

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