Treehouse - Request for Learner's Permit

Your Relationship to Driver:*

(Select the option that best describes your relationship with the participant.)

Self Request (Youth/Driver)
Caregiver, Guardian or Parent
Social Worker
Tribal Case Manager
Independent Living Specialist / Case Manager
Treehouse Education Specialist
Treehouse Launch Success Coach
Treehouse Advocate

Your Name:

(Who is filling out this form?)

First Last

Your Email:

(Please enter your email so that we can provide you with updates about your request.)

Participant's Name:*

(Who needs payment assistance?)

First Middle Last

Participant's License Number:*

(This is the driver's Washington State DOL PIC or WDL number found on the Identification card.)

Participant's Date of Birth:*

Participant's Phone:*

(If the participant does not have a personal phone, please input the number for the person who will have the most contact with them.)

Participant's Email:*

(Must be participant's unique email address.)

Participant's Address:*

(Where is the participant living?)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Does the driver currently qualify as one of the following?:*

(Participants must meet one of the following criteria to be eligible for Treehouse's Driver's Assistance program.)

Foster Care - Washington State Dependent
Foster Care - In-home Trial Return
Extended Foster Care - Foster to 21
Tribal Jurisdiction - Indian Child Welfare (ICW)

Participant's Tribal Association:

Participant's Social Worker:*

First Last

Social Worker Email:*

Social Worker Phone:

Participant's Tribal Contact:*

First Last

Tribal Contact Email:*

Tribal Contact Phone:*

Is the driver currently working with an Independent Living Specialist?:

Yes
No

Organization associated with Independent Living Specialist:

Name of Case Manager:*

First Last

Case Manager's Email:*

Case Manager's Phone:

Caregiver's Name:

First Last

Caregiver Email:

Caregiver Phone:

Caregiver's Address:

Street Address Address Line 2 City State ZIP Code

Total Amount Paid:*

We are currently providing reimbursements only for learner's permits.

Upload Receipt:*

Please provide a receipt for services or items paid. Be sure this shows the date, participant name, total amount paid, and business/vendor name.

Drop files here or

Accepted file types: jpg, gif, png, pdf, Max. file size: 256 MB.

Would you like your reimbursement by check or PayPal?*

Check
PayPal

For PayPal reimbursement payments:*

Please enter the name, email address, phone number or handle associated with the PayPal account.

Pay to:*

Who will Treehouse need to write a check to?

First Last

Mailing Address:*

Where should Treehouse send this check?

Street Address Address Line 2 City State ZIP Code

Treehouse Driver's Assistance Release of Information*

Driver’s Assistance is pleased to provide financial support for your driving goals. In order to successfully process payments and as a condition of enrollment, Treehouse requests permission to communicate, request, and exchange documents and details from/with your driving school during enrollment in the program. Please review and ensure that all the information entered above is correct.

I understand that Treehouse is only accessing information for the purpose of making payments and any data collected will be used solely for Treehouse's Driver’s Assistance Program.
I accept and agree to all of the above and that I have reviewed the information entered above and certify that all the above is correct.

We would love to hear from you!

Please indicate below if you are willing to receive one to two surveys over the next 6 to 12 months. Your participation helps us understand how we can better support youth experiencing foster care.

Yes, send me the surveys!

Learner's Permit

Instructional/ Learner's Permit

DA - Reimbursement Request for Learner's Permit