Date:________________

_________________________________________ has been loaned the following instrument:

_____________________________________ Serial Number _____________________________

Brand________________________ Model _______________________ Condition   ___________

with the following accessories:

_____Mouthpiece

_____Neck Strap

_____Ligature

_____Mouthpiece Cap

_____Lyre

_____Flip folder

Parent’s Consent and Student Agreement

My child, __________________________________, has my permission to borrow this musical instrument from the Mandeville High School Band.  I/We will be responsible for maintaining the instrument in good working order.

• If any damage is done to the instrument while it is checked out to my child, I/we will be responsible for the payment of all necessary repairs.

• If any repairs are necessary, I/we will contact Mr. Soukup before having repairs performed.

• If the instrument is lost or stolen, I/we, the parents, will pay for replacement of the instrument (see handbook for guidelines).