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School Registration

Please fill this form out prior to scheduling a time to visit LifeTown.

1 Primary Contact

2 Secondary Contact

3 Students

4 Scholarships

5 Waiver

Primary Contact
Name*
First Last
Email*
Phone*
Position within School*
School Name*
School Address*
Street Address Address Line 2 City State ZIP Code
- 1st choice of date you would like to visit?
  Date Format: MM slash DD slash YYYY
  
  1st choice of date you would like to visit?
- 2nd choice of date you would like to visit?
  Date Format: MM slash DD slash YYYY
  
  2nd choice of date you would like to visit?

Secondary Contact
Name*
First Last
Email*
Phone*
Any other information we should be aware of

Students
Tell us about the students you will be bringing
School Type
- Elementary
- Middle
- High School
- Other
Other*
Number of Students*
How many visits would you like to come?*
Which days work best for you?*
- Select All
- Monday
- Tuesday
- Wednesday
- Thursday
Select all that apply

Scholarship Request
The cost to attend LifeTown will be $35 per student per visit for the 2019-2020 school year

Partial Scholarships are now available and all applications will be under review.

If you are applying for a scholarship, please explain how much assistance you are requesting.
Assistance Requested

After your registration is submitted, a waiver form will be emailed to you and must be filled out for each student that is going to participate in LifeTown programming.