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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
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Please return this form along
with the $100.00 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 $100 FEE.
THE REMAINING BALANCE FEE IS DUE THE FIRST CLASS NIGHT.
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