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Admissions

If you are interested in joining our waitlist for service please complete the form below and our Client Services Representative, Heather will be in contact. To contact Heather please email heather@horizon-ns.ca.

Horizon Application/Referral Form

Please enclose any supporting documentation (i.e.: educational reports/ medical reports etc.). Failure to include supporting documentation can delay the applicant’s admission.

Personal Information

Name *

First

Middle

Last

Address

Address Line 1

Address Line 2

City

Province

Postal Code

Phone

Date of Birth

Layout

Emergency Contact *

Phone Number 1

Phone Number 2

Email Address *

Are you registered with the Department of Community Services?

Yes
No

Care Coordinator

Do you receive support from Disability Supports Program (DCS)?

Yes
No

Care Coordinator

Do you receive support from the ESIA program (DCS)?

Yes
No

Case Worker

Referral Source

(if applicable)

Agency

Name *

First

Last

Position/Relationship

Address

Address Line 1

Address Line 2

City

Province

Postal Code

Phone

Fax

Email Address *

Education History

Layout

Name of School

Last Year Attended

Type of Program

Last Grade Completed

Reason for Leaving

Additional Programs Attended

(Including on the Job Training)

Name of Program/Facility

Layout

From

To

Type of Training Received

Name of Program/Facility

Layout

From

To

Type of Training Received

If possible, please include a copy of the applicant’s latest IPP report.

Click or drag a file to this area to upload.

Do you or are you suspected of having a learning disability?

Yes
No

If yes provide details

Employment History

Please include any Employment/Volunteer Experience

Employer

Position

Job Description

Layout

From

To

Reason for Leaving

Employer

Position

Job Description

Layout

From

To

Reason for Leaving

Health History

Please check all that apply:

Physical Disability
Learning Disability
Vision
Speech Impairment
Hearing
Intellectual Disability
Other (specify)

Physical Disability – Comments

Vision – Comments

Speech Impairment – Comments

Hearing – Comments

Intellectual Disability – Diagnosis

Other – Please specify *

Layout

Family Physician

Phone

Are you currently on any medications?

Yes
No

Please list all medications *

Transportation

The Horizon Achievement Centre requires all participants to arrange their own transportation to and from their placements.

Have own Vehicle

Can secure drive with:

Takes the Bus

Walks

Comments Section

Describe why you are applying to this organization

Signature of Applicant

Clear Signature

Date of Application

Horizon Achievement Centre
258 Ferry Street, Sydney
Nova Scotia, Canada B1P 0K6

Phone 902-539-8553
Fax 902-567-0415

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