Forms

Individual Membership Form
Team Membership Form
2016 Scholarship Application – The MCC will provide a $500 scholarship to a worthy clogging individual for the Fall of 2016. Deadline for applications is April 1, 2016.

Team Insurance Forms: 

A benefit of membership in the MS Clogging Council is the availability of inexpensive insurance for your entire team.
This insurance covers your place of dance (studio, exhibitions, or competitions) and your dancers if an accident were to occur.
The coverage time is January 1 to December 31 of the current year.
There is no prorating of fees, so apply early to be insured for the entire year!

Here you will find information about how to apply for insurance, what to do if there is an accident, and other information.
If you have any questions, contact Carol Hosch, Insurance Chairman, at insurance@msclogextravaganza.com


Steps to Apply for Insurance

There are several forms that must be completed to apply for insurance. A list directions and forms are below:
1. Your team must be a member of the MCC. This is separate from individual memberships. The team fee is $10 per year.
Link to Team Membership Form
2. Complete the Non-Affiliate Club Listing Form. The “Club” is your clogging team name. Complete the “Facility Being Used” with information about your primary place of practice. You may list more than one practice facility. “Name as Additional Insured” should only be filled out if this is required by your facility. “Date of Function” should be your class meeting day (Mon & Tues, every Thurs, etc.)
Link to Non-Affiliate Club Listing Form
3. Complete the Club Roster Form. “Council” is Mississippi Clogging Council. ALL members of your team must be listed on this form. This is a group insurance policy, so all members of your group must be included. If you have members that are already covered under this insurance from another team, put them on the next form.
Link to Club Roster Form
4. If you have dancers insured through another team, complete the Club Roster Form for Dancers Insured Through Another Club. Members only need to pay the insurance fee once per year even if they dance with multiple teams.
Link to Club Roster Form for Dancers Insured Through Another Club
5. Make one check or money order from your team payable to USDA for $5.75 per dancer. Please do not send individual checks.
6. Return all forms and payment to Carol Hosch, 5025 15th St, Meridian, MS 39307.
7. You will receive a certificate in the mail when all forms have been accepted at the National Office.
8. Fill out the Inspection of Premises Form. This form is for your records and should not be returned to the Insurance Chariman.
Your practice facility should be inspected to note any unsafe areas, broken objects, etc. for which the team could be found liable.
Link to Inspection of Premises Form


If you have already applied for insurance and now have new members that need to be added, fill out the Additional Enrollment Form.
This form requires payment of $5.75 per dancer. Mail form and one check or money order made payable to USDA for the total amount to Carol Hosch, 5025 15th St, Meridian MS 39307.

Link to Additional Enrollment Form

Each performance, exhibition, competition, or any other clogging event in which your team participates must be reported to the Insurance Chariman to be covered in an accident. 

If it is a recurring event, list “Every 2nd Monday” as the “Date of Function”.
The Group Travel part of this form only applies if your team is travelling as a group on a commercial flight, chartered bus, etc.
If your venue requires a Certificate of Insurance, fill out the Request for Certificate form.
Mail or email this form to Carol Hosch.

Link to Event Notification Form


Each location where you dance should be inspected for safety.
Fill out the Inspection of Premises Form before each dance. This form is for your records and should not be returned to the Insurance Chariman.
The venue should be inspected to note any unsafe areas, broken objects, etc. for which the team could be found liable.
Link to Inspection of Premises Form

If the location where you are dancing requires a Certificate of Insurance, fill out the Request for Certificate form.
This must be requested at least 6 weeks prior to the event.
Mail or email this form to Carol Hosch.

Link to Request for Certificate Form

In the event of an accident, fill out the Club Accident Report form. Use this form any time there is an injury, no matter how minor.
If it turns into something major, you will have documentation about the accident.
This must be completed within 48 hours of the event.
Mail or email this form to Carol Hosch.

Link to Club Accident Report Form