CHCI Music - Instrument & Mouthpiece Contract
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 select the ensemble(s) that you participate in. *
Please record your instrument and number *
ie. Trumpet #7
Please record your mouthpiece and number *
ie. Clarinet Mouthpiece #21 (if you have your own mouthpiece, indicate that here)
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. *
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This form was created inside of WATERLOO REGION DISTRICT SCHOOL BOARD.