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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*

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

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

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*

Signed Date*

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

Employer

Contact Number

Supervisors Name/Title

Paid
Unpaid

Date Started

Date Ended

Job Duties

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

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.

Contact our team to discuss your needs or fill out the short form below and we will get back to you. Thank you.