References Form

This reference request should be given to a person who has known you for at least one year, and have personal knowledge about your employment history, education or character and can attest to your ability to provide in-home supports. Minimally, two references should be from former or current employers. References CANNOT be from family members. United Cerebral Palsy of Southern Arizona (“UCPSA”) by fax: 520-795-3196, email: staff@ucpsa.org or mail to 630 N. Craycroft Road, Tucson, AZ 85711.

APPLICANT

Applicant's Name(Required)

Applicant's Address(Required)

Street Address City State ZIP Code

Applicant's Phone(Required)

PERSON PROVIDING REFERENCE

Please complete the questions listed below keeping in mind that direct care services are typically performed unsupervised in the home of a person with physical or developmental disabilities. Your time and effort in completing this form is appreciated, and UCPSA will exercise strict confidentiality in regard to your responses within the provisions of the law.

This reference request MUST be returned to UCPSA at the address listed above.

Print Person's Name Providing Reference(Required)

Address(Required)

Street Address City State ZIP Code

Email(Required)

Daytime Phone

Evening or Cell Phone(Required)

State the length of time you have known the applicant:

Years(Required)

Months(Required)

Type of relationship (Check all that apply):(Required)

Supervised applicant

Worked with applicant

Friend

Neighbor

Other

Other(Required)

How do you believe the applicant will relate to individuals with physical and/or developmental disabilities? Describe any characteristics and/or special training or education that the applicant may have that will help the applicant work with people with disabilities, including the elderly.(Required)

Do you have any reason to believe that the applicant would not be suited to provide services to individuals with developmental disabilities?(Required)

If the applicant was a former employee, would you rehire this person?(Required)

Yes

N/A

If NO, why not?(Required)

Additional Comments which will help in evaluating this applicant.

Person's Signature providing reference(Required)

Date(Required)

Contact Us!

Get in touch and we’ll get back to you as soon as we can. We look forward to hearing from you!

Locations

Located just north of the Craycroft and 5th Street intersection, on the northeast corner.

UCP of Southern Arizona
630 N. Craycroft Road
Tucson, AZ 85711-1450

English / Español: 520.795.3108

Toll Free: 888.433.3629
On Call: 520.548.4969
Workability: 520.344.8250
FAX: 520.795.3196
E-mail: staff@ucpsa.org
Workability E-mail: workability@ucpsa.org

We have a regional office serving the cities south of Tucson (Sahuarita to Nogales).

UCP of Southern Arizona
1131 S. La Cañada Drive, Suite 105
Green Valley, AZ 85614

English / Español: 520.347.6950

On Call: 520.955.1706
FAX: 520.347.6917
E-mail: staff@ucpsa.org

We also provide services in Yuma!

UCP of Southern Arizona
333 W. 8th Street
Yuma, AZ 85364

English / Español: 928.259.7700

On Call: 928.750.5554
FAX: 928.259.7697
E-mail: staff@ucpsa.org

DONATE

References Form

APPLICANT

PERSON PROVIDING REFERENCE

Contact Us!

Locations

Tucson

Green Valley

Yuma