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New London Tri-Share Application

Required

Participant Information Form
General Dynamics Electric Boat Employees: Submissions are limited to one child per employee. Please only submit information in the Child 1 section. Thank you. 
Must contain a date in M/D/YYYY format
If you do not see your employer listed, they may not participate in the Tri-Share program.
Must contain a date in M/D/YYYY format

Personal Details: 

Employee

Namerequired
First Name
Last Name
Proof of residency required

Parent 2 or Legal Guardian Details (If Applicable)

Name
First Name
Last Name
Proof of residency required

Income Information

Legal Guardian(s) Weekly/Monthly Gross Wage

Proof of income required (see below)
Proof of income required (see below)
Proof of income required (see below)

Licensed Childcare Provider Information

Do you currently have a licensed childcare provider?required
Current Provider Details (if applicable)
Is the provider licensed by the State of Connecticut?
Do you need help locating a licensed childcare provider? If so, do you prefer
Type of Care

Child(ren) to be enrolled in childcare

Child 1

 

Namerequired
First Name
Last Name
Must contain a date in M/D/YYYY format
Days of the Week Childcare is Neededrequired
Beginning at ____ to _____

Child 2

General Dynamics Electric Boat Employees: Submissions are limited to one child per employee. Please only submit information in the Child 1 section. Thank you. 

Name
First Name
Last Name
Must contain a date in M/D/YYYY format
Days of the Week Childcare is Needed
Beginning at ____ to _____

Child 3

General Dynamics Electric Boat Employees: Submissions are limited to one child per employee. Please only submit information in the Child 1 section. Thank you. 

Name
First Name
Last Name
Must contain a date in M/D/YYYY format
Days of the Week Childcare is Needed
Beginning at ____ to _____
 

Income verification

Tax Returns:

Provide a copy of your most recent federal and state tax returns, including all schedules and attachments.

Address Verification

Utility bills: Submit copies of recent utility bills, such as electricity, gas, or water bills, in your name and showing your Connecticut address. 

Lease agreement or mortgage statement: A copy of your current lease agreement or mortgage statement, indicating your Connecticut address.

All required documents should be emailed to apaolillo@learn.k12.ct.us

 

Acknowledgement 

If approved, I agree to promptly notify LEARN, Early Childhood Education Department, of any changes to the above information. 

I attest that the child is not receiving any other subsidies (i.e Care4Kids). 

This form is legally binding. By signing below, I confirm that all information provided is accurate. Providing false information could result in the termination of Tri-Share Child Care services. 

Parent/Guardian 1 SignaturerequiredElectronic Signature
First Name
Last Name
Electronic Signature
Must contain a date in M/D/YYYY format
Parent/Guardian 2 SignatureElectronic Signature
First Name
Last Name
Electronic Signature
Must contain a date in M/D/YYYY format
General Dynamics Electric Boat Employees: Submissions are limited to one child per employee. Please only submit information in the Child 1 section. Thank you.