Treehouse - Request for Reimbursement

What is your relationship to the youth driver?*

Select the option that best describes your relationship with the youth.

Your Name:*

Who is filling out this form?

Your Email:*

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

Your Phone Number:*

Youth Driver's Name:*

Who needs payment assistance?

Youth Driver's Date of Birth:*

Youth Driver's Phone:*

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

Youth Driver's Email:*

Must be participant's unique email address.

Youth Driver's Address:*

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)

Youth Tribal Association:

Youth Driver's Social Worker:*

First and Last Name

Social Worker Email:*

Social Worker Phone:

Youth Driver's Tribal Contact:*

First and Last Name

Tribal Contact Email:*

Tribal Contact Phone:*

Is the driver currently working with an Independent Living Case Manager?

Yes
No

Organization associated with Independent Living Program:

Name of Independent Living Case Manager:*

First and Last Name

Independent Living Case Manager Email:*

Independent Living Case Manager Phone:

Caregiver's Name:

First and Last Name

Caregiver Email:

Caregiver Phone:

Caregiver Address:

Street Address City, State, Zip Code

Reimbursement Category:

Please specify the type(s) of service you are seeking reimbursement for.

Washington State ID
Learner's Permit
Driver's License
Driver's Education
Additional Practice Driving / Behind-the-Wheel Instruction
Missed Drive / Cancellation Fee / Fines
Driver's Testing Fee

Youth Driver's License Number:*

Please provide the driver's Washington State DOL PIC or WDL number found on the Identification card, permit or license.

Name of Driving School:*

What was the estimated start date for the Driver's Education Course?

What was/is the estimated end date for the Driver's Education Course?

Total Amount Paid:*

Driver's Assistance is able to provide a maximum of $750 for reimbursement of Driver's Education courses.

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.

Upload Receipt(s):*

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, png, pdf, Max. file size: 100 MB, Max. files: 3.

Pay to:*

Who will Treehouse need to write a check to?

First and Last Name

Mailing Address:*

Where should Treehouse send this check?

Street Address 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!

Reimbursement Request

Request for Reimbursement

DA Reimbursement