Instrument Maintenance Form

Date turned into Mrs. Neidhold______________________

Please fill in all YELLOW sections.  Mrs. Neidhold will fill in the remaining information.

MAINTENANCE AGREEMENT FOR THE USE OF INSTRUMENTS

OWNED BY WASHOE COUNTY SCHOOL DISTRICT

2012-2013

I, The Undersigned Parent or Guardian, of_____________________________________________________

                                                                             (Student Name)

Grade_________at Billinghurst Middle School.    Date:____________________________

Agree To The Following Conditions for the Rental of the Following Instrument:

________________   ________________   ________________   ________________  _________________

Instrument                  Size                                Manufacturer              Music Dept. No.         WCSD Tag No.

String Attachments:    Case________Bow ________ Shoulder Pad________Rock Stop/Strap__________

You Must Read & Initial Numbers 1 through 7.

_______        1.   To be personally responsible for any damage or replacement costs which may occur to this instrument while it is checked out to my child;

_______        2.   I understand that if my student is using a WCSD instrument, we will need to provide the necessary supplies for this instrument for the duration of the use of the instrument. (See list on back of form);

_______        3.   To have needed repairs checked first by the Instrumental Teacher who will then contact a repairman specified by Washoe County School District;

_______        4.   That only said child will use this instrument and that it will be used in preparation for and playing in Washoe County Schools and community organizations;

_______        5.   To return said outfit on demand; Possible reasons being:  A) Unsatisfactory effort and progress by pupil, B) Lack of reasonable care of outfit, C) Repeated damage to instrument;

_______        6.   To return said outfit to the Instrumental Teacher of the above school at the end of the current year in as good condition as received;

_______        7.   To submit the sum of $50.00 as the Maintenance Fee (non-refundable) for use of this instrument owned by Washoe County School District.  Cash, money order or certified checks preferred.

Parent Signature______________________________           Student Signature_____________________________

Address___________________________________________________________     Phone_____________________

              (Include City/Zip)

Email____________________________________                 Cell Phone __________________________________

$50.00 Attached:  Money order, cash or certified check “Billinghurst Middle School”  Money Order OR Certified Check. __________  Cash Amount __________

Condition Rented: ____________________ Condition Returned: __________________ Date Returned: ______________________ Instrumental Teacher Signature