Enhanced Horizons

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

Applicants Name*
First Last
Applicants Age*
Applicants Primary Diagnosis*
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*
Activity Sponsor*
How are you able to contribute to the activity*
Activity Location*
Total Cost of Activity*
Deposit Required*
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 Iowa to use my likeness
I consent to let The Arc of the Quad Cities Iowa 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*
Untitled

Activity Information