Georgetown College Department of Music
Instrument Checkout Form

Date January February March April May June July August September October November December 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 2008 2009 2010 2011	Course Select One MUS 213 MUS 214 MUS 215 MUS 216 MUS 217 MUS 314 Other
Professor Select One Sonny Burnette John Campbell Angela Easterday Jana Flygstad Michael Fogler Marilyn Harris Peter LaRue Eloise Lewis H. M. Lewis Glenna Metcalfe Rebecca Miller Mark Tate Elizabeth Telling Stephen Tilford
Instrument to be checked out Select One Baritone/Euphonium Bassoon Clarinet Clarinet--Bass Flute Horn Oboe Percussion Piccolo Saxophone--Alto Saxophone--Baritone Saxophone--Tenor String--Bass String--Cello String--Viola String--Violin Trombone Trumpet Tuba
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
String	Violin Cello Bass Box Rosin
Case Number/Instrument Number
Model
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