Texas Association,

Family, Career and Community Leaders of America

Please use the Tab key on the keyboard to move to the next field.  Do not use apostrophes or commas when submitting the Affiliation Form or Member Roster.

1.   Chapter  Name               Region    I II III IV V Chapter ID#          

School Name          

Address              

City           State           Zip           Zip +4 Ext.

(Area code) Telephone #    (Area code) Fax #

2.     Co-curricular Chapter?    Yes No

3.    School Location?    Urban Suburban Small Town Rural

4.    Check your school type:    Middle School Junior High/Intermediate Senior High Combined Jr/Sr High Other (Vocational, etc.)

5.    Chapter Membership:

# of Males this submission

# of Females this submission

Total # this submission

Total # YTD

6.    # of Comprehensive and Technical students     # of Occupational Specific students for this submission.

7.    Race/National origin. Enter number of members below for this submission:   

American Indian or Alaskan Native              Asian or Pacific Islander              Hispanic    

White, not of Hispanic origin              Black, not of Hispanic origin

8.    Total # of Special Populations students this submission:             

9.    Advisor:    Ms. Mr. Mrs.  

First name           MI Last Name

Address              

City           State           Zip           Zip +4 Ext.

(Area code) Telephone #    (Area code) Fax #

10.    Best time of day to contact 8 - 9  AM 9 - 10 AM 10 - 11 AM 11 - 12 NOON 12 - 1 PM 1 - 2 PM 2 - 3 PM 3 - 4 PM 4 - 5 PM 11.    Years as Advisor          

12.    Advisor email Address:          

13.    List additional Advisors for this Chapter:    (List addresses and contact information)

     

    

14.    Dues: Both state and national dues must be paid for each member.  
Overpayment of $10.00 or less will not be refunded.  Name substitution is not allowed.

Which dues payment of the school year?    1st 2nd 3rd or more

STATE ($7) & NATIONAL ($9) DUES		RATE	=$	AMOUNT
# Members                         This Submission		x $16.00 each ($144.00 minimum)	=$
Advisor Contribution (optional)		$ discretionary	=$
	Total		=$

Method of payment made payable to Texas FCCLA and Affiliation form MUST be sent to: FCCLA Lock Box Operations; PO Box 1326, San Antonio, TX  78295-1326  (NO CASH OR PURCHASE ORDERS ACCEPTED)

Check Type	Check Number	Amount
School Personal Money Order Other
School Personal Money Order Other

Each Member's national dues includes $3.50 for a one-year subscription to Teen Times Magazine.

revised 8/2007           

Do Not forget to fill out the Membership Roster Form

 PRINT THIS FORM IN LANDSCAPE FORMAT