Confirm:
Reminder:

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Student Information

 
Parent/Guardian Information

Name		Home Phone
Address		Work Phone
City		Zip
Email

 
In Case of Emergency Contact

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 

I hereby authorize Southeast Polk Schools to release any information necessary in regards to Free and Reduced status in regards to scholarship for driver education.

Parent Sign Here __________________________________________________________________________________________________

Payment plans available. Call or Email for details.

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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