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)		 Amount
Friend Discount
Full CS-249 Mon - Thur: 6/6 - 6/21 8:00 - 11:00 AM $335 $325
CS-250 Mon - Thur: 6/6 - 6/21 11:30 - 2:30 PM $335 $325
CS-251 Mon - Thur: 6/6 - 6/21 2:45 - 5:45 PM $335 $325
CS-252 Mon - Thur: 6/6 - 6/21 6:00 - 9:00 PM $335 $325
CS-253 Mon - Thur: 6/25 - 7/12 8:00 - 11:00 AM $335 $325
CS-254 Mon - Thur: 6/25 - 7/12 11:30 - 2:30 PM $335 $325
CS-255 Mon - Thur: 6/25 - 7/12 2:45 - 5:45 PM $335 $325
CS-256 Mon - Thur: 6/25 - 7/12 6:00 - 9:00 PM $335 $325
CS-257 Mon - Thur: 7/16 - 7/31 8:00 - 11:00 AM $335 $325
CS-258 Mon - Thur: 7/16 - 7/31 11:30 - 2:30 PM $335 $325
CS-259 Mon - Thur: 7/16 - 7/31 2:45 - 5:45 PM $335 $325
CS-260 Mon - Thur: 7/16 - 7/31 6:00 - 9:00 PM $335 $325
CS-261 Mon - Thur: 8/2 - 8/16 8:00 - 11:00 AM $335 $325
CS-262 Mon - Thur: 8/2 - 8/16 6:00 - 9:00 PM $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 along with the $125.00 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 $125 FEE. THE REMAINING BALANCE FEE IS DUE THE FIRST CLASS NIGHT.
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