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

Waukee Schools: COST ONLY $310
   Students will be required to show a valid Iowa instruction permit.
    

  Session Dates Class Times
Full 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?

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

Parent Sign Here ___________________________________________________________________________________________________

Return this form & the $310.00 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 $310 FEE.
 Back To StreetSmarts