MOUSE CA Single-Site Renewal Form

If you are interested in continuing a MOUSE Squad, 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 renewing multiple sites, you might find it more convenient to use the Multi-site Renewal Form instead.]

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.

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. Describe the impact your MOUSE Squad implementation and activities have had on students, teachers, staff and community.
  2. What activities were included in your MOUSE Squad implementation?
  3. Did you create a site-specific certificate for your students? Yes  No
  4. 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:
  5. When do you plan to continue MOUSE Squad at your site?:
    Month: Year (yyyy):
  6. Days and times of the program:
  7. Approximate number of students:
  8. Do you (or do you plan to) incorporate STEM/STEAM learning at your site?    Yes  No
  9. Do you (or do you plan to) incorporate Career Tech Ed learning at your site?    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.