Olathe District Schools Music Instrument/equipment Check-Out Form
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2Olathe District Schools
MUSIC INSTRUMENT/EQUIPMENT CHECK-OUT FORM
We provide larger, more expensive instruments & some donated instruments in case of financial need.
Kids deserve the opportunity to succeed, and we hope they continue to play in middle school band.
STUDENT: _____________________________________________________PHONE:___________________________
ADDRESS: __________________________________________CITY:____________________ZIP:_________________
GRADE: __________________________________________SCHOOL:_______________________________________
EQUIPMENT or INSTRUMENT CHECKED OUT: _______________________________________________________
MAKE: _________________________MODEL:______________SERIAL NUMBER: ___________________________
SCHOOL OF ISSUE: ____________________________ SCHOOL OF INVENTORY:___________________________
CONDITION OF
EQUIPMENT
______Excellent
______Very Good
______Good
______ Fair
______Poor
CASE
______Excellent
______Very Good
______Good
______ Fair
______Poor
SPECIFIC PROBLEMS (dents, latches, etc.):___________________________________________________________
ACCESSORIES BEING ISSUED:
______Mouthpiece
______Ligature
______Cover
______Strap
______Swab
______Bow
______End Pin Rest
______Polishing Cloth
______Sticks/Mallets
______Mute
Other:_____________________________________________________________
APPROX. VALUE OF INSTRUMENT/EQUIPMENT BEING CHECKED OUT: _______________________________
We, parent(s) and student do hereby agree to be responsible for this instrument / equipment and agree to pay for negligent damages
that occur beyond normal wear and tear, as identified by a certified instrument repairman. We further agree no other individual(s)
will use this equipment and it will be returned to the school where it was checked out when requested by the director. This instrument
is property of U.S.D. #233, Olathe, Kansas.
PARENT(S) SIGNATURE: _______________________________________DATE:_____________________________
STUDENT SIGNATURE: ________________________________________DATE:_____________________________
THIS INSTRUMENT WAS CHECKED OUT BY: _______________________________________________________
(NAME OF OLATHE SCHOOLS INSTRUMENTAL MUSIC STAFF MEMBER)
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