ATLAS Membership Rates & Discounts

Available Services	Member Rate	Non-Member Rate
Consultation & Evaluation
Assistive Technology Consultation	$200 per hour				$250 per hour
Assistive Technology Evaluation	$2,000 flat fee				$2,500 flat fee
Training
Individualized Training	$200 per hour		$225 per hour
Presentations & Demonstrations
Assistive Technology Presentation	$150 per hour			$200 per hour
12 hour “Suitcase Demo” Package	$3,000 flat fee			$4,000 flat fee
24 hour “Suitcase Demo” Package	$5,500 flat fee			$7,500 flat fee

Lending Library
Full Access to library tools and technology	FREE	N/A
Check out iPads, Switches, AAC software, EyeGaze and More!
Ask how you can get access to our training videos, how to guides and more!

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)
Comments
This field is for validation purposes and should be left unchanged.

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