2023 SSDA Registration - Student Contract

COVID-19 UPDATE: To support the health and safety of students and instructors, we sanitize shared surfaces. Wearing a mask is encouraged due to proximity in the vehicle, but it is not required.  

Thank you for choosing Street SMART Driving Academy, LLC. Please complete this registration form. You will need information from the student's learner's permit.

A copy of the Student Contract will be emailed to the parent email address or to the adult student email. Please PRINT AND SIGN the contract and bring it with you on the first day along with any other documents needed that are listed in the contract.

If you are taking an online course, you must register and submit payment on the Online Courses page on our website.

Payment for in-car training is due on the first scheduled day and can be made in cash or check made payable to SSDA.

If you have any questions, please contact Lolita Smart at 540-424-6844. Our email is ssda4u2@gmail.com
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First Name *
Last Name *
Do you have any physical or mental condition that may affect your ability to safely operate a vehicle? *
If you are currently attending high school or college please enter the name of your school here. If home schooled, please indicate.
Year in School
Clear selection
Date of Birth *
Age *
Clear selection
Address *
Please type full street address. There are some restrictions on pick up and drop off, contact us if you have any questions. We do not pick up/drop off in Western Loudoun.  Western Loudoun students must meet us in Leesburg for sessions.
City *
Zip Code *
Student Cell
Student Email Address
SAMPLE Learner's Permit
Learner's Permit Customer Identifier *
Permit Issue Date *
Permit Expiration Date *
Special Permit *
When applying for your permit were you required to submit special documentation from a medical professional? Important in determining if the student is eligible to receive the Road Test through SSDA or  DMV only.
Must be completed for all students under the age of 18.
Parent Name
Parent Email *
If student is Age 18+, please enter student email here. The SSDA Student Contract is emailed to this address and needs to be signed and printed.
Home Phone
Parent Cell
Emergency Contact Name *
Contact Cell *
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