»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
Payment plans available. Call or
Email for details.
Please 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. Back To StreetSmarts