MOUSE CA Single-Site Application Form

If you represent a school or district interested in implementing a MOUSE Squad, please answer this Application Form to the best of your ability. Responses to all questions are required. [NOTE: If you are applying for multiple sites, you might find it more convenient to use the Multi-site Application Form instead.]

Your Name:
First

Last

Position/Title
Site Name:
Site Address:
Street

City

ZIP
School District: County:
Contact Email: Contact Phone:

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
  1. How would MOUSE Squad Student Tech be a useful program for your site?
  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. Please provide the following information about your MOUSE Squad team:
    Site 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:
  6. When do you plan to begin MOUSE Squad at your site?
    Month: Year (yyyy):
  7. Days and times of the program:
  8. Approximate number of students:
  9. 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.)
  10. How did you hear about the MOUSE Squad Student Tech program (if from another website, please identify it)?
  11. Do you (or do you plan to) incorporate STEM/STEAM learning at your site?
    Yes   No
  12. Do you (or do you plan to) incorporate Career Tech Ed (CTE) learning at your site?
    Yes   No
  13. Interested in having a MOUSE Squad volunteer?
      Speaker for a Day
      Field Trip Host
  14. Any additional comments?
  15. Please enter this Validation Number.