We Kan Drive Referral

Due to recent changes at the state level, We Kan Drive will not enroll youth in a driving school until they have their original birth certificate and social security card available to them. We Kan Drive does not need a copy of the documents at this time, but driving schools will need a copy. The youth will need to take the originals to the DMV. The state ID form, Appendix 7, should also be filled out and signed by the CMP. This might be accepted at the DMV in lieu of a social security card. The youth should always take the form with them to the DMV, to avoid being charged for the permit/license.

Person Completing Referral

Please enter the information of the person completing the referral

Name(Required)

First Name Last Name

Relationship to Youth/Young Adult Being Referred(Required)

Self

Case Management Provider

DCF Independent Living Case Manager

Foster Parent

Other

Phone Number(Required)

Phone Number

Email(Required)

Other Relationship:(Required)

Please type another option here

Reason for Referral(Required)

Instructional Permit/Driver's License

Driver's Education

Insurance Assistance

Other

Other Reason:(Required)

Please type another option here

Name of Youth/Young Adult Being Referred

Please enter the information of the person being referred.

Name(Required)

First Name Last Name

Current Age

Birthday

Is the youth currently living on their own?(Required)

Yes

Address(Required)

Street Address Address Line 2 City State ZIP Code

Youth Phone Number

If applicable

Case Management Provider

Name(Required)

First Name Last Name

Phone Number(Required)

Email(Required)

Relationship to Youth(Required)

Case Management Provider

Independent Living Case Manager

Other

Other Relationship to Youth:(Required)

Please type another option here

Additional Comments/Questions

Please add any additional comments about the referral here.

Placement Information

Name(Required)

First Name Last Name

Phone Number(Required)

Email(Required)

Relationship to Youth

Foster Mother

Foster Father

Group Home

Other

Other Relationship to Youth:(Required)

Please type another option here

Group Home:(Required)

Please list the name of the group home.

Additional Contacts

First Name

Last Name

Relationship to Youth

Phone Number

Additional Comments/Questions

Please add any additional comments about the referral here.