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: ______________
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Non-Waukee High School Students: COST ONLY $335
    

  Session Dates Class Times
Full WAUKEE-19 Tue/Thur: 2/23 - 4/1 6:00 - 9:00 PM
WAUKEE-20 Tue/Thur: 4/20 - 5/20 6:00 - 9:00 PM
       

»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?

Return this form & the $135.00 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 $135 FEE. THE REMAINING BALANCE FEE ($200) IS DUE THE FIRST CLASS NIGHT.
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