Project SEARCH: Intern Application 2025 DONATE Personal DataName(Required) First Middle Last Present Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Cellular Phone NumberE-Mail Address(Required) Date of Birth(Required) MM slash DD slash YYYY GenderPrefer not to discloseMaleFemaleAre you a student? I am a student School Currently Attending(Required)Current DDS ProviderNameType of Service Add RemovePlease list name and type of service (GSE, Day, ISE, IDV etc.)Are any of your relatives currently employed at Backus Hospital or Hartford Healthcare? Yes No I yes, please provide their names:Do you have Husky C? Yes No Are you currently enrolled in CT Department of Developmental Services? Yes No Intern Candidate Information 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. 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(Required)Signed Date(Required) MM slash DD slash YYYY Future Employment Preferences and BackgroundWhat is your career of interest?(Required)How do you want to be employed in the community upon the completion of Project SEARCH?(Required) Full-time Part-time List jobs you do or have done in the school or in the community (paid or volunteer)EmployerContact NumberSupervisors Name/Title Paid Unpaid Date StartedDate EndedJob Duties Add RemoveEmployerContact NumberSupervisors Name/Title Paid Unpaid Date StartedDate EndedJob Duties Add RemoveList other jobs you do or have done in the school or in the community (paid or volunteer)Candidate Response QuestionWhy do you want to participate in Project SEARCH?(Required)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(Required)NameRelationshipPhone NumberEmail Address Add RemoveAssistanceThe person assisting the candidate to complete this application is:Name(Required) First Last Title(Required)Organization(Required)Phone Nuimber(Required)Email(Required) Signature(Required)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) EmailThis field is for validation purposes and should be left unchanged.
