MOUSE CA Multi-Site Renewal Form

If you are a district or organization that is interested in continuing a MOUSE Squad at multiple sites, please answer all of the questions in this Renewal Form to the best of your ability. Responses to all questions are required. [NOTE: If you are only renewing one site, you will find the Single-site Renewal Form more convenient.]

NOTE: If you are not a renewing or returning Squad, do not fill out this form. Please fill out the Squad Application form instead.

Once you have submitted this form, you will then be asked to complete the Registration Agreement and Letter of Intent.

Your Name:
First

Last

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

City

ZIP
Site #1 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 #2 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 #3 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 #4 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. Describe the impact your MOUSE Squad implementation and activities at your sites have had on students, teachers, staff and community.
  2. What activities were included in your MOUSE Squad implementation at your sites?
  3. Did you create a site-specific certificate for your students?      Yes  No
  4. When do you plan to continue MOUSE Squad at your sites?:
    Month: Year (yyyy):
  5. Days and times of each site’s program:
  6. Approximate number of students per site:
  7. How will you fund each site’s renewal fees for this year?
  8. Do you (or do you plan to) incorporate STEM/STEAM learning at your sites?    Yes  No
  9. Do you (or do you plan to) incorporate CTE learning at your sites?    Yes  No
  10. Interested in having a MOUSE Squad volunteer (check all that apply)?
      Speaker for a Day
      Field Trip Host
  11. Any additional comments:
  12.   Please enter this Validation Number.