2022-2023 ACES On-Line Application
Welcome to the 2022-2023 School Year.

Our 21stCCLC Mullica Township ACES (Afterschool Coyote Experiences) Program is available to ANY Students in Grades 3-8 at the Mullica Township School AND Cedar Creek HS 9-12th Grade Students who are residents of Mullica Township.

Please use this form to register your child(ren) for either our in-person AM/Morning ACES Program, our in-person PM/Afternoon ACES Program, or if you plan to utilize both our AM/PM ACES Sessions. When you complete this on-line registration, there will be a question where you will indicate the program(s) in which you wish to register your child.

Our AM Morning Program will operate IN-PERSON 1.5 hours (7AM-8:30AM) before school (parent required to sign child into program by 8AM) Monday-Friday Mornings on days when our school is in-session. AM Morning ACES will provide students with a healthy morning snack; Homework Help and Academic Support/Assistance; and Health and Wellness Activities. AM Morning ACES starts September 6, 2022.
 
Our PM Afternoon ACES will operate IN-PERSON  for 2 hours (3:35PM-5:35PM) after school over three (3) Cycles (September-December; January-March; April-June) on scheduled Mondays-Thursdays. Students will be assigned a schedule that will include: a healthy afternoon snack; Homework Help and Academic Support/Assistance; and participation in academic remediation and enrichment opportunities, as well as the opportunity to participate in activities targeting STEM, positive youth development, culture and the arts, and health/nutrition/fitness and physical activity. Our PM ACES Program will also provide themed-activities on “Wacky Wednesdays, Thrilling Thursdays and/or Fun Fridays”. Field Trip participation will be based on student attendance in program. PM Afternoon ACES will start the week of September 26, 2022.

Our 21stCCLC Mullica Township ACES Program will also offer a series of parent workshops and family-centered events and evenings throughout the school year.

*NOTE: Bus transportation to AM Morning ACES is not available. Courtesy bus transportation home from PM Afternoon ACES is available. ACES buses run along established activity bus routes with centralized stops along the routes. ACES bus stops are not the same as regular school day bus stops. Please answer our question regarding your need for transportation for ACES Staff to arrange our routes.

Regular student attendance is vital for our 21stCCLC ACES Program to receive continued federal funding. The Mullica Township 21stCCLC ACES Program requires 151 students to register a minimum of 30 days attendance to continue to receive funding. Student participation in ACES field trips and special Fun Friday activities will be based on program attendance.  

The 21stCCLC Mullica ACES Program operates under the governance of the Mullica Township School District and schedule is subject to change based on changing policies and/or guidelines.
 
Please complete this on-line registration form to enroll your child in our 21stCCLC Mullica ACES Program. All questions must be answered to complete and submit this application. If you have no response, please write N/A.

Questions or comments? Please e-mail: brheault@mullicaschools.com 
 
Sign in to Google to save your progress. Learn more
Email *
Student LAST NAME *
Student FIRST NAME *
Student Grade in 2022-2023 *
Required
Please sign my child up for AM Morning ACES. I understand that I must sign my child into the morning program no earlier than 7AM and no later than 8AM. *
Required
Please sign my child up for PM Afternoon ACES. *
Please sign my child up for BOTH AM Morning ACES and PM Afternoon ACES. *
Transportation needs (for PM Afternoon Program)
Clear selection
Primary Parent Contact NAME (FIRST/LAST) *
1st Contact Address *
Parent Phone *
Home Address *
2nd Parent Contact Name *
2nd Parent Contact Email *
2nd Parent Contact Phone *
2nd Parent Address *
Student Rights and Responsibilities Grades 3-12 (Please read and acknowledge) : *
Captionless Image
Required
Parent/Guardian Discipline Code Acknowledgement (Please read and indicate that you agree to code of conduct) *
Captionless Image
Required
Permission to Release AND/OR DO NOT RELEASE Student: Parent/Guardian is responsible to update school records (primary record for ACES Staff to access) to indicate the name, phone number, email of UP TO THREE persons to whom our SRO and ACES Staff may release children. Parent/Guardian is responsible to update school records (primary record for ACES Staff to access)  the names of any/all persons , and relationship to student, that our SRO and ACES Staff CANNOT RELEASE student to. PLEASE indicate in short answer box permitted individuals and/or persons we cannot release student to. *
Captionless Image
EMERGENCY CONTACTS - Please list the NAMES, PHONE NUMBERS, RELATIONSHIP TO STUDENT, ADDRESS, AND EMAIL of individuals that may be contacted if PARENT/GUARDIAN CANNOT BE REACHED. Parent/Guardian is required to update this information in OnCourse as ACES Staff will use OnCourse as a PRIMARY METHOD of checking for this information.  Please read and acknowledge the ACES Policy for Emergency Contacts in the short answer box below. *
Parent/Guardian acknowledgement of responsibility to update OnCourse records to: release student; to provide notification of individuals NOT permitted to sign-out child; and update emergency contacts. *
Required
Parent/Guardian acknowledgement that it is parent/guardian's responsibility to arrange safe passage to/from the school (if self-transporting) AND  includes appropriate supervision of child during dropoff and sign-in/sign-out (at MAIN ENTRANCE) AND includes pickup of student from the child’s ACES ACTIVITY BUS STOP - which may not be the regular school day bus stop. *
Required
EMERGENCY MEDICAL CARE 1 -  If my child requires emergency medical care and I cannot be reached, I give my consent to Mullica Township ACES Program to obtain the necessary medical care for my child.  I agree to pay all costs associated with the emergency medical care my child receives.  I understand every effort will be made to contact me before and after medical care is provided. *
Required
EMERGENCY MEDICAL CARE 2 - As parent/guardian I understand that this information is strictly confidential and will not be shared with anyone without my written consent or in the case of emergency medical care. *
Required
EMERGENCY MEDICAL CARE 3 - As parent/guardian I understand that following emergency medical care, my child may be released to the following people:  Write “same” if same as emergency contacts. *
HEALTH INSURANCE INFORMATION - Please add information listed in the picture to the text box. *
Captionless Image
EMERGENCY MEDICAL CARE 4 - I understand this consent will be in effect immediately and will continue as long as my child is enrolled in this afterschool program. *
Required
HEALTH RECORD 1 - **CONFIDENTIAL** HEALTH RECORD (To be completed by the parent or guardian) This confidential health record will only be used to ensure the safety of the children in this program.  This information will not be shared outside of this afterschool program.  Please respond with short responses to explain your answer to any/all item(s) in the chart. *
Captionless Image
HEALTH RECORD 2 - Parent/Guardian to list significant illnesses or surgeries.  Provide the date and any instructions. *
HEALTH RECORD 3 - Please provide any information about special situations or needs our ACES Program Staff should be aware of: ex. child has behavioral/emotional difficulties;  child has physical disabilities; child has limitations that would prevent him/her from participating in specific activities; activities that you believe would benefit your child; etc. *
HEALTH RECORD 4 - Special Health Care Needs: Does your child have special health care needs that require treatment and/or medication?  If yes, describe below. If your child requires treatment and/or medication during after-school hours, parent/guardian shall complete a Health Care Plan for a Child with Special Health Care Needs form with our School Nurse. *
HEALTH RECORD 5 - Medication: Does your child take medication for any condition or illness? If yes, describe below. If your child requires medication during after-school hours, parent/guardian must complete the Medication Consent form with our School Nurse and update all school medical records. *
HEALTH RECORD 6 - Sunscreen and Topical Ointments: Do you give permission to the after-school program to apply sunscreen or other over-the-counter topical ointments on your child? Please check YES or NO below *
PHOTO/VIDEO/INTERVIEW CONSENT:  I understand that the 21stCCLC Mullica ACES Program features special events both in-school and away from school.  Media representatives, newspaper and television reporters, photographers, and public-relations personnel may be present at these special events to record them.   In some cases they may interview and/or photograph children who participate in these events.  These photographs, videos, and interviews will only be used to promote the 21stCCLC Mullica ACES Program. In addition, I give permission for my child to be photographed or otherwise recorded during before/after-school events and activities, and for any and all such photographs or videos to be displayed by ACES AFTERSCHOOL PROGRAM at Mullica Township School in any medium (books, newsletters, web sites, social media, etc.) whether now or hereafter known or developed. IF I DO NOT PROVIDE CONSENT, I acknowledge that my child may not be able to participate in these events and activities. *
Acknowledgment of Nita M. Lowey 21stCCLC Mullica Township Schools AM/PM ACES Program GOALS and MISSION:  I acknowledge that it is the goal and mission of the 21stCCLC Program to offer high quality, hands on and inquiry based opportunities in a before and/or afterschool environment to all registered participants that will yield improved academic achievement, positive behavior, social interaction and parental involvement while preparing students for the 21st Century. I further acknowledge that the 21stCCLC Program is dedicated to providing a safe environment facilitated by nurturing adults where opportunities in academic remediation and enrichment, positive youth development, culture and the arts, health/nutrition/fitness and physical activity are provided. Opportunities and activities and programming for parental involvement are also offered, and that registered students will receive: remediation and enrichment in math, science and language arts; Tutoring & Counseling; exploration of the Arts: Cultural, Visual and Performing; Character and Mindfulness Education; Physical Fitness/Health and Wellness; Technology.   *
ATTENDANCE STATEMENT - Regular student attendance is vital for our 21stCCLC ACES Program to receive continued federal funding. The Mullica Township 21stCCLC ACES Program requires 151 students to register a minimum of 30 days attendance to continue to receive funding. Student participation in ACES field trips and special Fun Friday activities will be based on program attendance.   *
Required
FINAL CONSENT, PROGRAM ATTENDANCE ACKNOWLEDGMENT FORM, AND PERMISSION SLIP TO ATTEND ALL ACES ACTIVITIES/FIELD TRIPS FOR THE 2022-2023 SCHOOL YEAR:  My child has my PERMISSION to participate in the Nita M. Lowey 21stCCLC Mullica Township School ACES Program and may attend Wacky Wednesday/Thrilling Thursday/Fun Friday and SPECIAL ACES EVENTS. I recognize that transportation will not be offered for AM Morning ACES. I acknowledge that regular ATTENDANCE is vital for the ACES Program to receive federal funding, and understand that my child is required to “check-in” to a minimum of 30 days daily attendance (AM ACES, PM ACES, Special Events, Fun Fridays) while a registered participant. *
Required
PARENT AND STUDENT PRE-SURVEY: In the box below, please list activities, trips or events you would like to see ACES Program offer, and/or please feel free to make suggestions or offer ideas you might have about the ACES Program. THANK YOU for completing our Application! (If you have no suggestions or remarks, please enter "NONE" in the remarks box below.) *
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of MULLICA TOWNSHIP SCHOOL DISTRICT. Report Abuse
Google Forms