Confirm:
Reminder:

StreetSmarts Driver Registration Form
 www.streetsmartsdriversed.com

Students will be required to show a valid Iowa instruction permit.

** Office Use Only **
Date: _________________
Check #: ______________
Amount: ______________
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Bondurant Farrar Schools

(Please mark your session)
 

Session

 Dates Class Times Amount
(Check/Money Order)
BF-9 Tue & Thur: 3/27 - 4/27 6:00 - 9:00 PM $335
BF-10 Mon - Fri: 5/30 - 6/12 7:00 - 10:00 AM $335
         
         

»Please enter information carefully. This form is used to type your certificates.
Student Information
Name (Full)   Zip  
Address   Date of Birth  
City   What Grade Are You In?  
Phone   Age on last Birthday?  
Permit #   Permit Expiration Date  
School attended this year?  

Parent/Guardian Information
Name   Home Phone  
Address   Work Phone  
City   Zip  
Email      


In Case of Emergency Contact
Name   Phone  
Preferred Hospital      
Doctor   Phone  

Does the student have any physical or learning disabilities? Yes No If yes, please explain on back of page.
How did you hear about us?

Check below (only choose one option and fill in email or phone number you want to be contacted by.)
To receive confirmation by email  
To receive confirmation by phone 


Payment plans available. Call or Email for details.

Please return this form & the $335.00 registration fee to:
StreetSmarts, P.O. Box 71658, Clive, IA 50325
  
Please call us at (515) 279-1112 for more information, questions or concerns. Please note your session dates and times on your calendar. Confirmation will be made by phone or email after registration is received. No refunds after the first class session. RETURN THIS FORM TO THE ABOVE ADDRESS WITH THE $335 FEE.


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