School Instrument Rental 19-20
Student Last Name
Student First Name
School (Please choose one)
Indian Hills Elementary
Pauline South Elementary
Washburn Rural Middle School
Washburn Rural High School
Address (Street, City, St, Zip)
Parent Telephone (Home or Cell)
Parent Telephone (Work)
Type of Instrument (If other, please specify)
What is the serial number? (Most likely on the case, check the instrument as well)
Date of Issue (What day you got it)
Items that came in/with your case (please check all that apply, if other please specify):
Case or Bag
By checking the box below it is understood that the instruments and accessories checked above are to be issued to the student listed and that the instructor has confirmed the eligibility of the student. The instrument is loaned under the following conditions: 1. The student agrees to maintain satisfactory progress through daily practice. 2. The student agrees to take proper care of the instrument as directed by the instructor. 3. The student agrees to participate in activities and programs scheduled for the band/orchestra of which he/she is a member. 4. The instrument will be checked-in to the music instructor by the end of the year for inspection and reassignment, or when requested by the instructor. 5. The music instructor will be notified immediately of any vandalism or theft. 6. The student and parents have paid the fees necessary to use the instrument for the semester or year.
I agree to the terms listed above
Type name and initial to verify agreement to the terms (Example: John Doe JD)
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This form was created inside of Auburn-Washburn USD 437.