StreetSmarts Driver Registration Form
www.streetsmartsdriversed.com

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

 

Brody Middle School

Session Dates Class Times Amount (Check/Money Order) Amount Friend Discount BRODY-37 Mon - Thur: 6/6 - 6/21 8:00 - 11:00 AM $335 $325 BRODY-38 Mon - Thur: 7/16 - 7/31 8:00 - 11:00 AM $335 $325

»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? Signing up with a friend? Enter their name 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

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. Back To StreetSmarts