Texas Clogging Council Membership Application
[Print this page, complete and send to address listed at bottom of form.]

Date                                                 [__]New Membership            [__] Renewal Membership

Name(s)___________________________________________________________________ 

E-Mail__________________________________________________ (Primary Contact Only)

Date(s) of Birth
(1) (2) (3) (4)

  (Respectively, of those listed above for insurance purposes)

Address___________________________________________________________________________________

City__________________________ State____  Zip __________-________ (Must have +4 for Mailing)

Day Phone [____]_______-_________                          Night Phone  [____]________-____________

        I [__] DO            I [__] DO NOT    belong to a club/team.

Name of Club_______________________________________________________________________________

Name of Director____________________________________________________________________________

Annual Membership Fees

$15.00  Primary member   (per household)                                                 $ 
(Includes dues, insurance and subscription to THE TEXAS CLOGGER.)

 
$8.00 Additional Fee for subscription to Step-In-Time                                                 $ 
(Our cue-sheet publication.)

 
$10.00 Each additional member  (same household)                                                 $ 
$10.00 Club Registration Fee 
(Paid by Club Director annually on March 1 with a completed Club Membership Application)		                                                 $ 

  
TOTAL ENCLOSED                 $ 

Make checks payable to THE TEXAS CLOGGING COUNCIL(TCC) and mail completed application(s) to:

T.C.C. MEMBERSHIP CHAIRMAN
c/o J C GAFFORD
P. O. Box 622
Ace, TX 77326
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