LifeTown Columbus 2025-2026 Application Form
Please complete the form below to request visits and/or a scholarship to LifeTown. This form must be completed prior to scheduling visits on Calendly. ***Columbus City Schools: Please do not complete this form***
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
This application is for:
*
Single class or school
Entire school district
County:
*
District
*
School (if applicable):
My students are:
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Elementary
Middle
High
Number of Students:
*
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Primary Contact Information
First Name:
*
Last Name:
*
Address:
*
City:
*
State:
*
Zip Code:
*
Email
*
example@example.com
Phone Number:
*
Please enter a valid phone number.
Format: (000) 000-0000.
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Special Education Director Information
First Name:
*
Last Name:
*
Email
*
example@example.com
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Superintendent Information
First Name:
*
Last Name:
*
Email
*
example@example.com
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Elementary School Information
Please tell us about the students you will be bringing.
Number of Students
*
Number of Visits (*please indicate between 4-6 per school year*)
*
Total Number of Visits (# of students x # of visits)
*
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Middle School Information
Number of Students
*
Number of Visits (*please indicate between 4-6 per school year*)
*
Total Number of Visits (# students x # of visits)
*
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High School Information
Number of Students
*
Number of Visits (*please indicate between 4-6 per school year*)
*
Total Number of Visits (# of students x # of visits)
*
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Scholarships
Please read the following carefully: Each visit to LifeTown is valued at $135 per student per visit. Partial scholarships allow LifeTown to reduce the cost for all applicants to $55 per student (an $80 scholarship/student) as a baseline. We are now offering additional scholarships. If you are applying for an additional scholarship to reduce the cost beyond $55/student per visit, please complete the remaining sections before submitting. If not, you may skip the next page and submit.
I am applying for an additional scholarship.
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Yes
No
I am requesting a scholarship of:
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Please provide the amount you are requesting. This is calculated as # of students x # of visits x $ per visit being requested. For example, if you are requesting a scholarship of $55 per student for 4 visits and 20 students, the above would say: "20 x 4 x 55 = $4,400".
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Scholarship Information
Student Demographics
Rows
Up to 25%
25-50%
50-75%
75-100%
African American
Asian
Caucasian
Hispanic
Other
Percentage of students receiving free or reduced lunch:
Up to 25%
25-50%
50-75%
75-100%
LifeTown receives state funding that allows us to provide substantial scholarships for schools and districts who have students that are eligible for TANF. We can accept documentation/data your school/district may already have OR we can provide you with the ODJFS TANF Non-Assistance Eligibility Form for TANF Funded Services. Are you able to provide documentation/data, from your district or parents/guardians, demonstrating eligibility for TANF (Temporary Assistance for Needy Families) assistance for your students OR are you willing to utilize the ODJFS form (send home with students for parents/guardians to complete)?
*
Yes
No
If you answered no to the above, please explain.
Please explain in one to two sentences how life, social, and pre-employment skills training at LifeTown will benefit your students.
Please verify that if selected for a scholarship, district/school agrees to the following. All boxes must be checked.
*
We are reserving the amount of contracted visits and are obligated to pay for those visits.
Every attempt will be made to reschedule cancelled visits. In the event the schedule does not permit make-up visits, the school district is still obligated to pay for those contracted visits.
Any unused visits will be forfeited.
Any increase to the contracted visits will be charged at a reduced rate.
We will actively request photo releases from guardians/parents for students and teachers.
Teachers will be asked for a formal testimonial of their experience at LifeTown.
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