Enhanced Horizons 2022 Application - The Arc of The Quad Cities Area

Enhanced Horizons is offered to Scott County residents with a primary diagnosis of intellectual or developmental disabilities.

Applicants Name
First Last
Applicants Age
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
What waiver services do you receive?
Have you ever received previous Enhanced Horizons Funding
Primary contact name
First Last
for person filling out application
Primary contact phone
for person filling out application
Agency/Relationship to applicant
Primary contact email

for person filling out application
Activity Information
Name of Activity
Activity Attending
Is your Activity Confirmed
Acitvity Sponsor
Activity Location
Total Cost of Activity
Deposit Required
How are you able to contribute to the activity
Name of contact person for this activity
First Last
Email of contact person for this activity
Phone of contact person for this activity
Consent
I consent to let The Arc of the Quad Cities Iow to use my likeness
I consent to let The Arc of the Quad Cities Iow to use my likeness of me in photos, videos, or audiotapes for future advertising and fundraising as long as my likeness is needed.
I Do Not Consent
I do not allow The Arc of the Quad Cities Iowa to use my likeness
Signature
I acknowledge that printing my name below is substitute of my manual signature
By typing your name below. You are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature.
Name

Activity Information