BCMS INSTRUMENT CHECK OUT FORM

Name: __________________________________ Phone: ______________________

Address: _____________________________
_____________________________

The school instrument listed below is loaned to the above student for the ___________school year:

Instrument: ________________________________ Make/Model: __________________

Serial #: _______________________________ Value: _________ Finish: ___________

Condition:__________________________________________________________________________

___________________________________________________________________________________

________________________________________________________________________________

Accessories Loaned: Case Mouthpiece Strap Ligature Other: ___________

The following conditions apply:

• You are responsible for the repair of any damage to the instrument during the time that the
instrument is in your care.
• You will return the instrument in the same condition that it was given to you.
• You are responsible for the proper care of the instrument.
• The instrument must be returned at any time requested.
• Due to the limited number of instruments owned by the school, your use of the instrument
may be precluding another musician from using it. Therefore, you agree to be a positive
contributor to the program by practicing and maintaining proper instrument care.

Student Signature: ____________________________ Date: __________

Parent Signature: _____________________________ Date: __________

Return this signed form to your director.

School instruments may not be brought home until this form is returned.
Thank you.