Texas Clogging Council Stipend Application
Completed application and reimbursement receipts should be sent to:

Kayla Barton, Education Director
2703 Taylorcrest
Missouri City, TX 77459
(812) 568-5069
or
tcckaylab@yahoo.com (preferred)
GENERAL INFORMATION
Applicant Name (Last, First, Middle Initial): *
Permanent Address: *
How long have you been a member of the Texas Clogging Council? *
What activities (academic, clogging, community service, etc.) are you currently involved in or have been involved with relating to the goals and objectives of the Texas Clogging Council? *
Please describe the activity for which you are seeking a stipend. *
Total amount of stipend requested: *
Please send registration receipts reflecting this amount to tcckaylab@yahoo.com
My electronic signature below certifies the information provided in this application is accurate and complete to the best of my knowledge. *
Date: *
MM
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DD
/
YYYY
Telephone Number: *
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