Candidate Intern Application

To Parents & School Administrators: UCP can attend IEP meetings to further explore the benefits of this internship program for students.

PLEASE CALL US FOR MORE INFO AT 860.443.3800 x306
Kia Baird, Project SEARCH Coordinator

Selection Process Guidelines

Completing this application does not guarantee placement.
The Selection Committee will only accept fully completed applications. Any incomplete application will be disregarded, and the Intern Candidate will not be accepted. If accepted, the Intern Candidate must be able to pass a criminal background check and drug screen.
If accepted, an IEP will be developed with the IEP team.

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
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
MM slash DD slash YYYY
Final acceptance is contingent upon the completion of the following:
Candidate must complete a personal history disclosure form and obtain a vendor badge from The Mohegan Sun Gaming Commission. This involves presenting a copy of a birth certificate and a CT Picture ID.
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.

Save and Continue Later

Name	Type of Service

Name	Relationship	Phone Number	Email Address

Project SEARCH: Application

Candidate Intern Application

To Parents & School Administrators: UCP can attend IEP meetings to further explore the benefits of this internship program for students.

Selection Process Guidelines

Personal Data

Referral Contact Information

Intern Candidate Information

Future Employment Preferences and Background

Candidate Response Question

References:

Assistance

Final acceptance is contingent upon the completion of the following:

School Personnel Only