MOUSE Squad Membership

Please check if the following are true.: *

My School/Organization intends to join the MOUSE Squad program for the 2011-2012 school year!

My School/Organization has budgeted for the $999 membership fee.

My principal is committed to providing me and my new MOUSE Squad with all the resources necessary to run a successful squad.

Full School or Organization Name: *

School DOE Number (example: M345):

Address:

City / State / Zip:

Phone:

Free & Reduced Lunch Rate (0-100%):

Principal Name:

Principal Email:

The Primary MOUSE Squad Coordinator:

Name: *

Position at School: *

E-Mail: *

Name:

Position at School:

E-mail:

How do you plan to run your MOUSE Squad? (check all that apply):

I will run MOUSE Squad as a class using the MOUSE Squad Certification curriculum.

I will run MOUSE Squad as an elective using the MOUSE Squad Certification curriculum.

My students will receive school credit for MOUSE Squad.

My students will be paid to participate.

My MOUSE Squad will be an official school club.

My Squad will be an after-school program.

My Squad will meet during the school day on lunch breaks or free periods.

My Squad will meet in the mornings before school begins.

I have not decided yet.

Total Faculty: *

How many teachers does your school have? (approx.)

Total Students: *

How many students are currently enrolled in your school? (approx.)