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