CHCI Music - Instrument & Mouthpiece Contract

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Welcome (or welcome back) to the Cameron Heights Music Program! As your child is either taking an instrumental music class or is participating in an extracurricular band, they will be assigned an instrument and a mouthpiece that they may use at school and also borrow for home practice. In order to borrow this equipment, financial responsibility (in case of loss or damage through carelessness or neglect) must be assumed by a parent or guardian. Please complete and submit the form below.

Student Name *

Last name, First name

Parent/Guardian Name *

Last name, First name

Select the class that you are enrolled in below *

Select your teacher *

Please record your instrument and number (the one on the outside of the case) *

ie. Trumpet #7

Please record your mouthpiece and number (the one engraved somewhere on your mouthpiece) *

ie. Clarinet Mouthpiece #21 (if you have your own mouthpiece, indicate that here)

Did your mouthpiece come in a plastic case or have a mouthpiece cap? *

Yes

I have also borrowed (and assume responsibility for) *

Neckstrap (saxophones and bass clarinets)

Percussion stick bag (including all mallets and sticks)

I assume responsibility for the above listed instrument and mouthpiece for the duration of the semester/ensemble year. I understand that in the event of damage to the above equipment that has occurred through a deliberate act, or negligence I may be required to pay for the repair or replacement of the equipment listed above. *

Student acknowledgement of responsibility

Parent/Guardian acknowledgement of responsibility

Required

Please have parent/guardian email your teacher to confirm they have seen and agreed to this contract. Mrs. Howard: katelynn_howard@wrdsb.ca, Ms. Park: ann_park@wrdsb.ca, Mr. Scott: wesley_e_scott@wrdsb.ca *

Yes, my parent has emailed my teacher

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This form was created inside of WATERLOO REGION DISTRICT SCHOOL BOARD.