Home Phone (required)
Are you a U.S. citizen or authorized to work in the United States?
Do you have a valid driver's license?
Do you have reliable transportation?
Do you know any foreign languages?
Do you know sign languages?
Have you worked as a personal assistant before?
If 'yes' please describe:
Have you ever applied with Impact CIL before?
Have you ever been convicted of a crime?
If 'yes' please explain?
Employment History: Please list most recent first
Reason for leaving:
I authorize IMPACT CIL. to release this application and/or certification and training information to consumers of IMPACT's Personal Assistant Program for the specific purpose of considering my application for employment. I also understand that I have the right to inspect the material which is being released.
I understand that when I complete the Personal Assistant Training, whether it is one-on-one or group training, I am authorizing IMPACT CIL. to give my name and Social Security Number to the Division of Rehabilitation Home Services Program for their use in tracking the actual employment of trained Personal Assistants.
I understand that this application and initial interview does not guarantee that I will be selected to participate in the Personal Assistant Program or that I will be hired as a Personal Assistant. I understand that if I am hired as a Personal Assistant, I will not be an employee of IMPACT CIL.
I, the undersigned, acknowledge that all the information that I have given on this Personal Assistant application is true and accurate to the best of my knowledge.
Signature of Applicant: (required)
Check all that apply: (required)
Alton/GodfreyBethalto/Cottage Hills/MoroCollinsville/Maryville/TroyEdwardsville/Glen CarbonGranite City/Madison/VeniceBond CountyWood River/East Alton/Harford/Roxana/South RoxanaCalhoun CountyGreene CountyJersey CountyMacoupin CountyRural Madison CountySt. Clair County
Please answer all questions, even if you are unsure about the correct response.
1. Individuals with disabilities can never do anything for themselves and always need help making decisions.
2. People with disabilities tend to live sheltered lives and will usually have a hard time learning new skills.
3. People with disabilities are considered to be sick people, similar to a patient in a hospital.
4. The relationship between a personal assistant and their employer is a professional one and should be treated the same as any other work relationship.
5. You can only get a pressure sore from laying in bed too long.
6. Someone with Cerebral Palsy is always considered mentally retarded.
7. If you have questions about your employer's health, the first person you should ask is:
Your employerThe doctorYour employers parents
8. You are helping your employer take a bath and the phone rings. What do you do?
Answer the phoneNot answer the phoneYou employer makes the decision
9. Your employer is having a "special day" and wants to eat something, not in her/her diet. Who decides whether or not he/she can do so?
The personal assistantThe employer
10. What is the best phrase to use?
A crippled personA person with a disability
11. Please describe what you think a personal assistant does.
12. What should you do if you can not make it to work during a time of illness or emergency?