MSCA: Squad Application Form

MOUSE Squad Application Form

If you represent a school or district that is interested in implementing a MOUSE Squad, please answer all of the questions in the Application Form below to the best of your ability. Responses to all questions are required.

Your Name:	First	Last	Position/Title
Site Name:
Site Address:	Street	City	ZIP
School District:
County:
Contact Email:
Contact Phone:

How would MOUSE Squad Student Tech be a useful program for your site?
In what activities are students already engaged related to student technical support?
What are your feeder schools and districts?
What are your destination schools and districts?
What community or business partnerships do you have for potential volunteers, field trips and/or funding?
What tools do you have in place to measure the impact of MOUSE Squad on student achievement, and the benefits to students, teachers and the school as a whole?

Please provide the following information about your MOUSE Squad team:

TEAM MEMBER	FIRST NAME	LAST NAME	POSITION/TITLE	EMAIL
MOUSE Squad Coordinator/Instructor
School/agency administrator who will be working with MOUSE Squad

When do you plan to begin MOUSE Squad at your site? Month: Year (yyyy):
What is your site's percentage of Free/Reduced Meals?
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.)
How will you fund the renewal fee for each of years 2 and 3 to sustain the program?
Would you like to apply for a MOUSE Squad Mini-Grant (see Funding page for more information)?
Yes No
How did you hear about the MOUSE Squad Student Tech program (if from another website, please identify it)?
Any additional comments?
Please enter this Validation Number.

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