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MUSIC DEPARTMENT
INSTRUMENT CHECKOUT/IN
2015-2016
NAME__________________________________Student
ID#_________________
Address______________________________________________
_________________City
________________________State___________________Zip__
____________
Cell Phone___________________Student
email_________________________
Parent/Guardian Cell
phone_____________email_____________________
Insttrument:_____________________Serial
Number____________________
Condition at Check Out___________________Check
In_________________
Replacement Cost_______________________
I promise to treat the Independence High School Music
Department instrument listed above as if it were my own
personal property. By signing this agreement my parents
and I understand that we will be held financially liable for
any excessive damage to the instrument or its theft while it
is in my possession.
Student
Signature/Date______________________________________________
_____
Parent/Guardian
Signature/Date__________________________________________