Enhanced Horizons 2026 Application
The Arc of the Quad Cities Iowa
Applicants Name
*
First Name
Last Name
Age
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Primary Diagnosis
*
Do You Receive Waiver Services
*
Yes
No
If Yes, Which Waiver?
*
Information for person filling out application
Name of person filling out application
*
First Name
Last Name
Phone
*
Agency/Relationship to applicant
*
Email
*
example@example.com
Activity Information
All Information is Required
Name of Activity
*
Date of Activity
*
-
Month
-
Day
Year
Date
Cost of Activity
*
$00.00
Activity Sponsor & Location
*
Amount You Are Requesting
*
$00.00
Amount of Deposit Required
*
$00.00
How much are you able to contribute to the cost of the activity?
*
$00.00
Name, phone number and email address of the contact person for this activity
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
I agree to let Arc of Quad Cities Iowa use any likeness of me in photos, videos or audiotapes for future advertising and fund raising as long as my likeness is needed.
*
Agree
Do Not Agree
Date of Application
*
-
Month
-
Day
Year
Date
Submit
Should be Empty: