The Arc of Scott County – Enhanced Horizonsfor 2017 (Page 1)
The Arc of Scott County is pleased to announce the continuation of the leisure and recreation program Enhanced Horizons, funded by the Davenport chapter of The Knights of Columbus Tootsie Roll Drive. This program is offered to Scott County residents witha primary diagnosis of Intellectual and/or Developmental disabilities. The Arc can provide monetary assistance to qualifying individuals up to $250 a year to enroll in leisure activities, with a $150 limit per activity application. These activities can include, but are not limited to, art classes, dance/music lessons, membership to local museums/zoo, local camps, sporting/musical events, fair passes and supervised vacations.
One application per activity.The Arc of Scott County is an organization completely run by volunteers. All decisions on applications are final.
Applications will be reviewed monthly beginningFeb 1, 2017and ending when funds are depleted, normally before May 1st. Please allow one month to process each application. Our funds ARE limited; therefore our intent is to fund activities for individuals that could not participate without financial assistance.
- Enhanced Horizons does not pay deposits.
- The checks will be written to the provider and if not used, the checks should be returned to the Arc office. All checks are void after 60 days.
- Email questions to:
Applications are available through The Arcof Scott County website, Hand in Hand, New Choices, Family Home Health Care, and the Handicapped Development Center.
------
Contact information for person filling out application:
Name ______Agency ______
E-mail ______@______
(Application will not be processed if this information is not included)
Applicants Name: ______Age:______
Address: ______City: ______Zip: ______
My Primary Diagnosis is: ______
Which waiver services do you receive? ______
Turn application over to complete other side.
The Arc of Scott County – Enhanced Horizons for 2017 (Page 2)
Please complete both sides of the application.
Leisure Activity Information:
Name of activity: ______ (1 activity per application)
Dates Attending: ______ Are you registered? ______
Activity location and by what company is it run? ______
Total Cost of Activity: ______ DepositRequired ______
How much are you able to contribute to the cost of the activity? ______
Name and phone number of the contact person for this activity:
Mail Completed applications to:
The Arc of Scott County, P. O. Box 1523, Bettendorf, IA 52722-0026
------
I agree to let Arc of Scott County use any likeness of me in photos, videos or audiotapes for future advertising and fund raising as long as my likeness is needed.
______
Consumer SignatureDate of application
FOR OFFICE USE ONLY 2017 Ver 3 Date Processed ______
Granted: ______Remaining:______Check # ______