Georgetown College Department of Music
Instrument Checkout Form


Instrument to be checked out
Woodwind Accessories
Mouthpiece Reed Case Lyre
M.P. Cap Neck Strap Cloth
Ligature Tuning Rod
Brass Accessories
Mouthpiece Oil Lyre
Mute Cloth
Percussion Kit
Bells Mallets Prac. Pad
Sticks Stand
Violin Cello Bass
Box Rosin
Case Number/Instrument Number
Serial Number
Condition of instrument (note 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.
Signature of Student
Initials of Faculty Member
Date of Return
Received in good condition by

Student Information

Campus address
Campus telephone number
Permanent address
Permanent telephone number