Thank you for your generous grants and donations. YOU help people with disabilities in CT lead lives without limits.

United Cerebral Palsy would like to recognize the following foundations and organizations for their generous grant awards to UCP and its various programs.

FOUNDATIONS & ORGANIZATIONS

Bodenwein Public Benevolent Foundation
Chamber of Commerce of Eastern Connecticut
Chelsea Groton Foundation
Community Foundation of Eastern Connecticut
David N. Lane Trust
Dime Savings Bank Foundation
Dominion Foundation
Electric Boat Employees Community Association
Frank Loomis Palmer Fund, Bank of America, N.A., Trustee
Frontier Employees
George A. & Grace L. Long Foundation
People United Community Foundation
RS Gernon Foundation
United Way Southeastern CT

DONORS & SPONSORS

Chelsea Groton Bank
Core Plus Credit Union
Doherty, Beals & Banks, PC
James Harris
Lloyd Johnson
Providence Mutual
Quincy Mutual Fire Insurance Group
Robert Burnside
Wave Construction Group
World Insurance
A Secondino & Sons
Bouvier Insurance
Chelsea Groton Bank
Clearpath Financial Services
Lathrop Vending
Stuart Bryan
Messier, Massad, Burdick & Associates
Diane Deedy
Betsy Ritter
Harry Colonis

UCP team receiving a donation of $5000 from Chamber of Commerce of Eastern CT

Thank you to the United Way of Southeastern Connecticut for your support during this turbulent time. United Way’s generous grant to our Disability Support Program, Inclusion and Advocacy will help us help our clients and their families during a time when they need it most. We’re proud to be part of the Partner Program at United Way. Together we provide vital support to individuals with disabilities in Eastern Connecticut to ensure they live lives without limits.

Personal Data
Name*
First Middle Last
Present Address*
Street Address Address Line 2 City State ZIP Code
Cellular Phone Number
E-Mail Address*
Date of Birth*
MM slash DD slash YYYY
Gender
Are you a student?
- I am a student
School Currently Attending*

Current DDS Provider

Name	Type of Service

Please list name and type of service (GSE, Day, ISE, IDV etc.)

Referral Contact Information
Referral Contact Name
First Middle Last
Referral Contact Email
Referral Contact Address
Street Address Address Line 2 City State ZIP Code
Referral Contact Cellular Phone Number
Referral Contact Signature
Referral Contact Signed Date
MM slash DD slash YYYY
Referral Contact Name
First Middle Last
Referral Contact Email
Referral Contact Address
Street Address Address Line 2 City State ZIP Code
Referral Contact Cellular Phone Number
Referral Contact Signature
Intern Candidate Information
1. Universal Release: I authorize the release of educational and employment records concerning the intern candidate from his or her school, DDS program or Employer to UCP of Eastern CT and Project SEARCH Partners.
2. Equal Opportunity: Project SEARCH placement will be made without regard to race, color, age, sex, national origin, cultural or economic background, housing circumstances is entitled to equal opportunity for educational development.
Candidate Signature*
Signed Date*
MM slash DD slash YYYY
Future Employment Preferences and Background
What is your career of interest?*
How do you want to be employed in the community upon the completion of Project SEARCH?*
- Full-time
- Part-time
List jobs you do or have done in the school or in the community (paid or volunteer)
Employer
Contact Number
Supervisors Name/Title
- Paid
- Unpaid
Date Started
Date Ended

Job Duties

<img data-src='https://ucpect.org/wp-content/plugins/gravityforms/images/list-add.svg' alt='' title='Add a new row' src='data:image/gif;base64,R0lGODlhAQABAAAAACH5BAEKAAEALAAAAAABAAEAAAICTAEAOw==' class='lazyload' /><noscript><img data-src='https://ucpect.org/wp-content/plugins/gravityforms/images/list-add.svg' alt='' title='Add a new row' src='data:image/gif;base64,R0lGODlhAQABAAAAACH5BAEKAAEALAAAAAABAAEAAAICTAEAOw==' class='lazyload' /><noscript><img src='https://ucpect.org/wp-content/plugins/gravityforms/images/list-add.svg' alt='' title='Add a new row' />

<img data-src='https://ucpect.org/wp-content/plugins/gravityforms/images/list-remove.svg' alt='' title='Remove this row' src='data:image/gif;base64,R0lGODlhAQABAAAAACH5BAEKAAEALAAAAAABAAEAAAICTAEAOw==' class='lazyload' /><noscript><img data-src='https://ucpect.org/wp-content/plugins/gravityforms/images/list-remove.svg' alt='' title='Remove this row' src='data:image/gif;base64,R0lGODlhAQABAAAAACH5BAEKAAEALAAAAAABAAEAAAICTAEAOw==' class='lazyload' /><noscript><img src='https://ucpect.org/wp-content/plugins/gravityforms/images/list-remove.svg' alt='' title='Remove this row' />

Employer
Contact Number
Supervisors Name/Title
- Paid
- Unpaid
Date Started
Date Ended

Job Duties

<img data-src='https://ucpect.org/wp-content/plugins/gravityforms/images/list-add.svg' alt='' title='Add a new row' src='data:image/gif;base64,R0lGODlhAQABAAAAACH5BAEKAAEALAAAAAABAAEAAAICTAEAOw==' class='lazyload' /><noscript><img data-src='https://ucpect.org/wp-content/plugins/gravityforms/images/list-add.svg' alt='' title='Add a new row' src='data:image/gif;base64,R0lGODlhAQABAAAAACH5BAEKAAEALAAAAAABAAEAAAICTAEAOw==' class='lazyload' /><noscript><img src='https://ucpect.org/wp-content/plugins/gravityforms/images/list-add.svg' alt='' title='Add a new row' />

<img data-src='https://ucpect.org/wp-content/plugins/gravityforms/images/list-remove.svg' alt='' title='Remove this row' src='data:image/gif;base64,R0lGODlhAQABAAAAACH5BAEKAAEALAAAAAABAAEAAAICTAEAOw==' class='lazyload' /><noscript><img data-src='https://ucpect.org/wp-content/plugins/gravityforms/images/list-remove.svg' alt='' title='Remove this row' src='data:image/gif;base64,R0lGODlhAQABAAAAACH5BAEKAAEALAAAAAABAAEAAAICTAEAOw==' class='lazyload' /><noscript><img src='https://ucpect.org/wp-content/plugins/gravityforms/images/list-remove.svg' alt='' title='Remove this row' />

List other jobs you do or have done in the school or in the community (paid or volunteer)
Candidate Response Question
Why do you want to participate in Project SEARCH?*
Complete in your own words and/or person assisting will write the responses in the candidate's own words.
References:
Please provide 3 references.

Required*

Name	Relationship	Phone Number	Email Address

Assistance
The person assisting the candidate to complete this application is:
Name*
First Last
Title*
Organization*
Phone Nuimber*
Email*
Signature*
Date
MM slash DD slash YYYY
School Personnel Only
- Completed Application Packet (Student/Family completes and submits)
- High School Transcript (Local School/EUPISD will submit on behalf of intern)
- Attendance Record (Local School/EUPISD will submit on behalf of intern)
- Current IEP (Local School/EUPISD will submit on behalf of intern)
- Most Recent Evaluation Team Report (Local School/EUPISD will submit on behalf of intern)
Email
This field is for validation purposes and should be left unchanged.

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