DBHS INSTRUMENT RENTAL FORM - 2017-18 SCHOOL YEAR

This year-long agreement is REQUIRED for all students who choose to utilize a school-
owned instrument from Dawson-Boyd Public Schools. It is understood that the student shall
keep, maintain, and be responsible for the full care and maintenance of their borrowed
instrument. The student will be responsible to pay for all damages to the instrument
incurred throughout the school year and is required to fully replace the instrument if the
damages are severe enough to render the instrument inoperable. The school will cover
normal wear and tear maintenance and cleaning through the general use of the instrument.

STUDENT NAME:_____________________________________________________

Instrument Needed: _________________________________________________________

(This portion to be filled out by Director)

Instrument Serial Number:

____________________________________________

Instrument
Brand/Model:______________________________________________

Instrument Locker Number:

___________________________________________
ACKNOWLEDGMENT AND AGREEMENT STATEMENT
Paid? Yes /
Print STUDENT name No
I, _____________________, understand that the issuance of this instrument to me places
me in the full care and maintenance of it. I agree to be financially responsible for any and
all repairs after I receive the instrument and promise to return this instrument and all
supplementary materials to the Dawson-Boyd Music Program at the end of the academic
school year in the same working condition in which it was when I received it.

Print PARENT name

I, __________________, understand that my child shall be responsible for the full care
and maintenance of their borrowed instrument and supplementary materials and I allow
them to use it as such for the academic school year. I also understand that my child will be
responsible for full replacement of the instrument if it is damaged to the point where it is
rendered inoperable and agree to replace the instrument if such damage occurs.

Student Signature_____________________________ Date of Signature_______________

Parent Signature______________________________ Date of Signature_______________