Street Smarts Driving School LLC. 119 West Court St. Viroqua, WI 54665 (608) 606-2371 Email: [email protected] Website: www.streetsmartsdriving.net Student Information: Last Name ____________________________________ First ________________________ Middle Initial ______ Street Address _______________________ __________ City __________________________ Zip Code __________ Student Phone# _________-_________-____________ Date of Birth _____/_____/_____ Parent Information: Last Name _________________________________ First ______________________________________ Phone Number _________-_________-__________ Email______________________________________ Sessions & Payments: please select (or you may complete the online form on our website) _____ Viroqua HS: June 8 th – June 26 th (Mondays- Fridays) Class will meet from 7:30 a.m.- 9:30 a.m. _____ 30 Hours In-Person Classroom + 12 Hours Behind The Wheel (6 driving & 6 observing) $350.00 _____Two payments of $175.00 will be accepted (full payment must be received before student starts behind the wheel) _____Only 30 Hours of Classroom $100.00 Please Select Your Method Of Payment (for in-person class only): _____Personal Check is enclosed with registration form payable to: Street Smarts _____ I have made a PayPal payment on your website: www.streetsmartsdriving.net Please mail or email this registration form to: Street Smarts Driving School 119 West Court St. OR [email protected] Viroqua WI 54665