DuPage County, Illinois
APPLICATION FOR VOCATIONAL AND DAY PROGRAM SERVICES
Revised: September 10, 2003
Please check
all of the following agencies that you want to apply to. Send a copy of this application to each
agency you choose.
__________ Parents
Alliance Employment Project __________ RRAF
2525 Cabot
Drive, Ste. 302 613
S. Main Street
Lisle, IL 60532 Lombard,
IL 60148
(630) 955-2079 (630)
495-7723
__________ Ray
Graham Association __________ Marklund
Attention: Intake Coordinator 164
Prairie, PO Box 10
2801 Finley Road Bloomingdale,
IL 60106
Downers Grove, IL 60515 (630)
529-2871
(630) 620-2222
__________ Helping
Hand
__________ Supported
Employment Associates, Inc. 9649
W. 55th Street
PO Box 4714 Countryside,
IL 60525
Wheaton, IL 60189-4714 (708)
482-9196
(630) 653-5662
__________ Spectrum
Vocational Services
2302 Wisconsin Avenue
Downers Grove, IL 60515
(630) 852-7520
__________ DuPage
County Health Department
422 N. Prospect
Wheaton, IL 60187
(630) 668-5850
__________ Other:
_________________________________________________________
Please
indicate the service(s) or program(s) that you are apply for:
_____ Job Placement / Supported Employment _____ Vocational
Evaluation
_____ Sheltered Workshop _____ Transitional Work or Transition
Services
_____ Developmental Training
Date of Application:
______________________________________________________________________
PERSONAL
INFORMATION
Name of Applicant:
_______________________________________________________________________
Person Completing the Application:
__________________________________________________________
(If different from applicant)
Address: ________________________________________________________________________________
(Street) (City)
_________________________________________________________________________________
(State / Zip) (Township) (County)
Phone Number(s): ________________________________________________________________________
Social Security Number: ________________________ Date of Birth:
________________________
Sex: _____ Male
_____ Female Marital
Status: ______________________
Are you receiving services from the Department of
Human Services/Office of Rehabilitation Services?
_____ Yes
_____ No If yes, who
is your counselor? _____________________________________
If yes, what is your DHS/ORS Case Number?
__________________________________________________
Do you receive any of these benefits? _____ Medicaid _____
Social Security (i.e. SSI, SSDI)
Do you have a driver’s license? _____ Yes _____ No
What is your mode of transportation:
_____ Own
vehicle _____ Taxi _____ Family or Friends
_____ Public Transportation (i.e. PACE Bus) If you use Public Transportation, are you
registered with PACE/RTA?
__________ ID #______________________
Do you use a Reduced Fare Card? _________ Do you use door-to-door services?
____________________
If we cannot reach you at your address and phone
number, is there another person we can reach?
Name: _______________________________ Street Address:
____________________________________
City/State/Zip: __________________________________ Phone: _____________________________
Relationship to you:
_______________________________________________________________________
Parent Information:
Mother’s Name: _____________________ Street Address:
____________________________________
City/State/Zip: _________________________________ Phone: _____________________________
Father’s Name: _____________________ Street Address:
____________________________________
City/State/Zip: _________________________________ Phone: _____________________________
What is your disability?
____________________________________________________________________
________________________________________________________________________________________
Do you have any physical limitations? Be specific. (i.e. Lifting restriction) __________________________
________________________________________________________________________________________
________________________________________________________________________________________
Do you use any assistive devices? Be specific. (i.e. Wheelchair,
Communication Aid) _________________
________________________________________________________________________________________
What are your skills and interests? (i.e.
Working with other, recreation activities, finding a full-time job)
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
GUARDIANSHIP
/ LEGAL STATUS
Do you have a legal guardian? _____ Yes _____ No
If yes, indicate the type of guardianship: _____
Full _____ Limited _____ Person _____ Estate
Guardian’s Name: __________________ Street Address:
____________________________________
City/State/Zip: ________________________________ Phone:
_____________________________
Relationship to you: ________________ Date guardianship established:
_______________________
If legal guardianship has been established, please
include a copy of the guardianship forms (Letters of Office) when returning
this application.
MEDICAL
INFORMATION
Do
you take any medications? _____ Yes
_____ No
If
yes, please list:
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Dosage |
Purpose |
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Have you been hospitalized or had surgeries? Please list:
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Name of Hospital |
Dates of Treatment |
Purpose |
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Special Medical Instructions or Information (i.e.
Must eat a snack due to low blood sugar) _____________
________________________________________________________________________________________
SERVICE
PROVIDER INFORMATION
Have you received or are you receiving services from
other agencies? (i.e. currently
attending a sheltered workshop, past rehabilitation programs) Please start with
the most recent:
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Name of Agency |
Dates |
Purpose |
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EDUCATIONAL
INFORMATION
Are you currently a high school student? _____
Yes _____ No
If yes, what is your graduation date or date you
will be exiting the public schools? _____________________
If yes, who is contact at your school?
_________________________________________________________
(Name) (Phone)
Please list High Schools and Post-Secondary Schools you
have attended or currently attending?
Begin with the most recent:
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Name/Address of School |
Dates Attended |
Type of Program (i.e. LD, BD, Multineeds) |
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List any additional classes or vocational training. Start with the most recent:
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Name/Address of School |
Dates Attended |
Type or Program |
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EMPLOYMENT
HISTORY
Please list information regarding your paid,
community employment history. Start
with the most recent. Use additional paper
as necessary.
1. Name of
Employer: _____________________________________________________________________
Address:
________________________________________________________________________________
(Street) (City) (State/Zip)
Phone: __________________________________ Dates of Employment: _______________________
Hours worked: __________________________ Rate of Pay:
________________________________
Description of Duties:
_____________________________________________________________________
________________________________________________________________________________________
Did you have help finding this job: _____ Yes _____
No Did you have a job coach: _____
Yes _____ No
If yes, who helped you?
____________________________________________________________________
Reason for Leaving:
_______________________________________________________________________
2. Name of
Employer: _____________________________________________________________________
Address: ________________________________________________________________________________
(Street) (City) (State/Zip)
Phone: __________________________________ Dates of Employment: _______________________
Hours worked: __________________________ Rate of Pay:
________________________________
Description of Duties:
_____________________________________________________________________
________________________________________________________________________________________
Did you have help finding this job: _____ Yes _____
No Did you have a job coach: _____
Yes _____ No
If yes, who helped you?
____________________________________________________________________
Reason for Leaving:
_______________________________________________________________________
3. Name of
Employer: _____________________________________________________________________
Address:
________________________________________________________________________________
(Street) (City) (State/Zip)
Phone: __________________________________ Dates of Employment: _______________________
Hours worked: __________________________ Rate of Pay:
________________________________
Description of Duties:
_____________________________________________________________________
________________________________________________________________________________________
Did you have help finding this job: _____ Yes _____
No Did you have a job coach: _____
Yes _____ No
If yes, who helped you?
____________________________________________________________________
Reason for Leaving:
_______________________________________________________________________
TRANSITION
INFORMATION
Complete this section only
if you are a High School Student or still in the public school system. Please ask your teacher or job coach to
assist you in completing this section.
Person completing this
section:______________________________________________________________
How do you learn the best or what is your learning
style? (i.e. Verbal Instructions, Two Step Instructions)
_______________________________________________________________________________________
________________________________________________________________________________________
What are your favorite classes or subjects in
school? _____________________________________________
________________________________________________________________________________________
What are some of your personal likes or dislikes
related to vocational programming or personal situations? (i.e. prefers to work alone, does not like
to be in crowds)
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
What services or supports are you receiving from
your school district?
_____ Speech Therapy _____
Social Worker _____
Social Skills Group
_____ Support
Group _____ Occupational
Therapy _____ Physical Therapy
______ Job Coaching _____
Visual Training _____
Hearing Services
_____ Transportation to employment _____
Other: ________________________
If you are receiving job coaching services, how much
time does a job coach spend with you?
_____ All the time that I work at my job _____ One hour each day I work
_____ One time per week _____ As I need assistance
_____ Other:
____________________________________________________________________________
Please list any training site or volunteer
experiences that you have had while in High School. Include paid and non-paid experiences.
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Location |
Type of Work or Experience |
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