MOUSE CA Multi-site Application Form

If you represent a district/community-based organization that is interested in implementing multiple MOUSE Squad sites, please answer all of the questions in this Application Form to the best of your ability. Responses to all questions are required. [NOTE: If you are only applying for one site, you will find the Single-site Application Form more convenient.]

Your Name:
First

Last

Position/Title
School District: County:
Contact Email: Contact Phone:
Site #1: Site Name:
Site Address:
Street

City

ZIP
Site Type (check all that apply):
Elementary School Non-school-based Community Based Organization (CBO)
Middle School School–based CBO
High School County Office of Education (COE)-Based program
Charter Private/Independent
Site #1 Team First Name Last Name & Position/Title Email & Phone
Primary MOUSE Squad Coordinator/Instructor
Pos:

Ph:
Secondary MOUSE Squad Coordinator/Instructor
Pos:

Ph:
Site administrator who will be working with MOUSE Squad
Pos:

Ph:
Person receiving the invoice for the MOUSE Squad program
Pos:

Ph:
Office Manager/School Secretary/Admin Assistant Pos:
Ph:
Site #2: Site Name:
Site Address:
Street

City

ZIP
Site Type (check all that apply):
Elementary School Non-school-based Community Based Organization (CBO)
Middle School School–based CBO
High School County Office of Education (COE)-Based program
Charter Private/Independent
Site #2 Team First Name Last Name & Position/Title Email & Phone
Primary MOUSE Squad Coordinator/Instructor
Pos:

Ph:
Secondary MOUSE Squad Coordinator/Instructor
Pos:

Ph:
Site administrator who will be working with MOUSE Squad
Pos:

Ph:
Person receiving the invoice for the MOUSE Squad program
Pos:

Ph:
Office Manager/School Secretary/Admin Assistant Pos:
Ph:
Site #3: Site Name:
Site Address:
Street

City

ZIP
Site Type (check all that apply):
Elementary School Non-school-based Community Based Organization (CBO)
Middle School School–based CBO
High School County Office of Education (COE)-Based program
Charter Private/Independent
Site #3 Team First Name Last Name & Position/Title Email & Phone
Primary MOUSE Squad Coordinator/Instructor
Pos:

Ph:
Secondary MOUSE Squad Coordinator/Instructor
Pos:

Ph:
Site administrator who will be working with MOUSE Squad
Pos:

Ph:
Person receiving the invoice for the MOUSE Squad program
Pos:

Ph:
Office Manager/School Secretary/Admin Assistant Pos:
Ph:
Site #4: Site Name:
Site Address:
Street

City

ZIP
Site Type (check all that apply):
Elementary School Non-school-based Community Based Organization (CBO)
Middle School School–based CBO
High School County Office of Education (COE)-Based program
Charter Private/Independent
Site #4 Team First Name Last Name & Position/Title Email & Phone
Primary MOUSE Squad Coordinator/Instructor
Pos:

Ph:
Secondary MOUSE Squad Coordinator/Instructor
Pos:

Ph:
Site administrator who will be working with MOUSE Squad
Pos:

Ph:
Person receiving the invoice for the MOUSE Squad program
Pos:

Ph:
Office Manager/School Secretary/Admin Assistant Pos:
Ph:
  1. How would MOUSE Squad Student Tech be a useful program for your sites?
  2. In what activities are students already engaged related to Student Technical Leadership?
  3. What are your feeder schools and districts?
  4. What are your destination schools and districts?
  5. When do you plan to begin MOUSE Squad at your sites?
    Month: Year (yyyy):
  6. Days and times of the program at each site:
  7. Approximate number of students per site:
  8. How are you funding MOUSE Squad for Year 1? (Note: After School STEM, Career Tech Ed, site or district program allocation, local businesses, foundations, and service organizations are a few of the sources that schools are using for MOUSE Squad Student Tech funding.)
  9. How did you hear about the MOUSE Squad Student Tech program (if from another website, please identify it)?
  10. Do you (or do you plan to) incorporate STEM/STEAM learning at your sites?
    Yes   No
  11. Do you (or do you plan to) incorporate Career Tech Ed (CTE) learning at your sites?
    Yes   No
  12. Interested in having a MOUSE Squad volunteer?
      Speaker for a Day
      Field Trip Host
  13. Any additional comments?
  14. Please enter this Validation Number.