MAKE A DONATION

United Way Donates $48,383 to UCP of Eastern CT

Your support makes a difference in the lives of people with disabilities in Connecticut, every day.

Your generous donations support our efforts to ensure that people with disabilities in Eastern CT enjoy full participation in their communities and that they are granted the same respect, equality and security as every member of society.

Donate by Mail

To donate by mail, please make your check payable to UCP of Eastern Connecticut and mail it to us at:
UCP of Eastern Connecticut
42 Norwich Road
Quaker Hill, CT 06375

Donate by Text

860.560.8375
Charges will appear on your wireless bill or be deducted from your prepaid balance. All purchases must be authorized by account holder. Must be 18 years of age or have parental permission to participate. Message and Data Rates May Apply.

Donate by Phone

Call us to donate by phone via credit card or if you have any questions related to the many was you can help us at UCP of Eastern Connecticut.

Contact Our Team

United Cerebral Palsy of Eastern Connecticut is an exempt organization as described in Section 501(c)(3) of the Internal Revenue Code; EIN 06-0792820

Read about our Milestones
in our 2020 Annual Report

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.

Save and Continue Later