Georgetown College Department of Music Instrument Check-Out Form

Instrument

 Bassoon
 Clarinet
 Flute
 Oboe
 Saxophone		 Baritone/Euph.
 Horn
 Trombone
 Trumpet
 Tuba		 Bass
 Cello
 Guitar
 Viola
 Violin

Other:
Brand/Model/Serial Number
Approximate Instrument Value $

Accessories
Included

 Bow
 Cleaning Cloth
 Cork Grease
 Crook(s)
 Ligature
 Lyre		 Neckstrap
 Mouthpiece
 Mouthpiece Cap
 Pick
 Reed Case
 Rosin		 Slide Oil
 Strings (extra)
 Swab
 Tuning Rod
 Valve Oil
Other
Condition of instrument, noting any defects

I acknowledge receipt of the above instrument and accessories.  I agree to be responsible for the repair of any damage while the instrument is in my care, including replacement costs if lost or stolen.  I agree to return the instrument at the conclusion of the term, or when requested to do so by the professor.
Student Signature Initials of faculty member issuing instrument
Date of Issue Date of Return
Received in same condition by

STUDENT CONTACT INFORMATION
Campus Address
Campus Telephone
Permanent Address
Permanent Telephone