Personal Assistant/Individual Provider Application

RAMP empowers people with disabilities to realize that there is no limit to what they can do. With this in mind, RAMP assists people with disabilities in obtaining the skills to hire and maintain Personal Assistants/Individual Providers (PA/IP).

PA/IPs assist with household tasks, personal care, appointment scheduling, and money management and, with permission of a doctor, certain health care procedures. PA/IPs are selected, employed and supervised by individual consumers.

RAMP maintains a list of Personal Assistants/Individual Providers and provides that list to the consumers we serve.

IMPORTANT – PLEASE READ THE FOLLOWING:

  • THIS IS NOT AN APPLICATION FOR EMPLOYMENT
  • RAMP DOES NOT EMPLOY PERSONAL ASSISTANTS/INDIVIDUAL PROVIDERS
  • ALL DECISIONS TO HIRE OR TERMINATE THE SERVICES OF A PERSONAL ASSISTANT/INDIVIDUAL PROVIDER ARE MADE BY THE CONSUMER AND NOT THE RESPONSIBILITY OF RAMP
  • WAGES FOR PERSONAL ASSISTANTS/INDIVIDUAL PROVIDERS ARE PAID THROUGH THE DIVISION OF REHABILITATION SERVICES (DRS) AND/OR THE INDIVIDUAL REQUIRING ASSISTANCE, NOT RAMP

Becoming a Personal Assistant/Individual Provider is a THREE STEP process:

    1. Complete the Personal Information Form online or in person
    2. AFTER you submit your online application, go back to the page to pay for the background check online via PayPal or in person ($20.00 non refundable fee online (includes processing convenience fee), $15.00 in person)
    3. Attend a mandatory orientation. In order to attend the orientation it is required that you bring a valid driver’s license and social security card with you to the orientation.

YOU WILL BE CONTACTED BY AN EMPLOYEE WITH RAMP TO SCHEDULE ATTENDANCE AT THE ORIENTATION AT THE RAMP OFFICE OR TO ADVISE YOU OF ANY ADVERSE FINDINGS ON YOUR BACKGROUND CHECK THAT MAY PRECLUDE YOUR ABILITY TO BE INCLUDED ON RAMP’S PA/IP REFERRAL LIST.

I understand that my application will not be accepted until I pay the background check fee.

YESNO

Personal Information


Date of Birth*

*Your date of birth is being collected to conduct a background check to confirm applicant eligibility to provide PA/IP Services in accordance with the Health Care Worker Act. RAMP reserves use of the information provided for the sole purpose of determining candidate eligibility to work as a PA/IP under the Health Care Worker Act. RAMP will advise an applicant if adverse information is found during the background check, provide a copy of the background check to the applicant – if requested and share with the applicant appropriate next steps.

Total hours available per week:

I would like to work: (choose all that apply)

Full TimePart TimeBack-Up

Do you have limitations to the type of work you can do?

YESNO

If yes, please explain so that we may have the best information available when sharing our PA/IP reference list:

Do you have a valid Driver's License or state ID card? You will be required to present at the time of your orientation.

YESNO

Do you have a working vehicle?

YESNO

If no, do you have alternatives to transport you to and from a potential job site? Please explain.

Employment History

Have you ever been terminated from a position? Please explain:



In the space provided, please provide the requested information for the last three (3) positions held:
Employer Name

Position/Job Title

From To

Responsibilities

Reason for leaving


Employer Name

Position/Job Title

From To

Responsibilities

Reason for leaving


Employer Name

Position/Job Title

From To

Responsibilities

Reason for leaving


References
Please provide the names and contact information of at least three (3) professional/personal references - not including family members):


How did you hear about the Personal Assistant Program?

If you have not already paid for your mandatory background check ($20 non-refundable fee online, or $15 via cash or money order in person at RAMP). If paying online for your background check, please click here. Once you click on the link you will be re-directed to a different page. Clicking on the link DOES NOT submit this form, you will need to come back to submit the application or submit your application now and go back to the Become a Personal Assistant page to make your payment.


I certify that answers given herein are true and complete. I further certify that if the information given is found to be false in any way, it shall be considered sufficient cause for denial of inclusion on RAMP’s PA/IP referral list and may include the inability to get on the list at any time in the future.

I authorize the use and investigation of any information in the application to verify my statements as it may be necessary in arriving at my eligibility to work as a PA/IP under the Health Care Worker Act. I release all such persons from any liability or damages on account of having furnished such information.

I hereby understand and acknowledge that I am filling out information to be on RAMP’s PA/IP Referral list and that, if added to the list; I am not an employee of RAMP.