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: ______________
Friend   Coupon

 

Clive, WDM, Urbandale, Waukee Area (Creekside Shopping Center)
CS = Creekside Shopping Center, 9914 Swanson Blvd, Clive, IA 50325
 

Session

 Dates Class Times Amount
(Check/Money Order)
Full CS-194 Mon/Wed: 4/26 - 5/26 6:05 - 9:05 PM $335 $310
Full CS-195 Tue/Thur: 4/27 - 5/27 6:05 - 9:05 PM $335 $310
 

»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

 
Please return this form along with the $110.00 registration fee to:
StreetSmarts, P.O. Box 71658, Clive, IA 50325
  
Please call us at (515) 279-1112 for more information, questions or concerns. Student will receive a reminder call the week before the class starts. 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 $110 FEE. THE REMAINING BALANCE FEE IS DUE THE FIRST CLASS NIGHT.
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