Locations

Quaker Hill Day Program and Administration Building

Quaker Hill Day Program and Administration Building

42 Norwich Road (Rt.32)
Quaker Hill, CT 06375

Old Saybrook Day Program

Old Saybrook Day Program

590 Boston Post Road
Old Saybrook, CT 06475

Groton Residential Program

Stratford Assistive Tech Library

Stratford Assistive Tech Library

300 Long Beach Blvd.
Stratford, CT 06615

UCP Stratford, CT

Stratford Assistive Tech Library
300 Long Beach Blvd.
Stratford, CT 06615

Directions

UCP Quaker Hill, CT

Administration and Day Program address is 42 Norwich Road this is also Route 32 in Quaker Hill, CT.

Directions from 395 North or South: 395 to Exit 6 (Rt 163) towards Uncasville/Montville. Go to end of ramp and turn left onto Route 163. Turn right onto Norwich New London Turnpike/CT-32. Continue to follow CT-32.

42 NORWICH RD is on the right

UCP Old Saybrook, CT

Day Program – Old Saybrook Site address is 590 Boston Post Road in Old Saybrook, CT

Directions from 95 South: 95 South to Exit 68 (US Route 1) and stay straight to go onto US-1 S. Turn left onto Boston Post Rd/US-1 S/CT-154. 590 BOSTON POST RD is on the left.

Directions from 95 North: 95 North to Exit 67 US Route 154) toward Old Saybrook. Merge onto CT-154 toward R R Station.590 BOSTON POST RD is on the left.

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

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

Job Duties

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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)
Name
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