MSCA: Squad Registration Form

MOUSE Squad Registration Form

If you are a new Squad site and your Squad Application has been accepted, or if you are a renewing or returning Squad, please complete and submit this Squad Registration form.

NOTE: If you have not yet filled out the Squad Application form AND received an acceptance, or 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 (a PDF document). If you miss that opportunity, you can always come back to this page or the Sign Up page to access the Registration Agreement.

Has your MOUSE Squad application been accepted? Yes No

Are you a renewing or returning Squad? Yes No

If you answered "NO" to BOTH of the above two questions, STOP HERE. Please fill out the Squad Application form instead. Thank you.

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

Start Date: Month: Year (yyyy):
Days and times of the program:
Approximate number of students:

Please provide the following information about your MOUSE Squad team:

TEAM MEMBER	FIRST NAME	LAST NAME	POSITION/TITLE	EMAIL & PHONE
Primary MOUSE Squad Coordinator/Instructor				Email: Phone:
Site administrator who will be working with MOUSE Squad				Email: Phone:
Person to receive the invoice for the MOUSE Squad program				Email: Phone:
Office Manager/School Secretary/Admin Assistant				Email: Phone:

Do you (or do you plan to) incorporate STEM/STEAM learning at your site?
Yes No
Do you (or do you plan to) incorporate CTE learning at your site?
Yes No
Interested in having a MOUSE Squad volunteer (check all that apply)?
Instructional Assistant
Help Desk Assistant
10-week Tech Leader
Speaker for a Day
Field Trip Host
Please enter this Validation Number.

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