HARRISBURG SCHOOL DISTRICT 41-2

Musical Instrument Rental Agreement

________________ School ____________________ Band Director Name

STUDENT’S NAME: _____________________________________________________________

PARENT/GUARDIAN NAME: ______________________________________________________

ADDRESS: _____________________________________________________________________

_______________________________________________________________________________

INSTRUMENT RENTED: __________________________________________________________

Brand: ____________________________

Serial Number: _____________________ DESCRIPTION OF CONDITION OF INSTRUMENT WHEN RENTED: (Include location and description of any dents, major finish scratches and tarnish, condition of case, condition of moving parts, pads, etc.) EXAMPLE: Several small dents in lower section; 2 med. Sized dents in bell; finish in fair condition (not much tarnish but scratched); valves work fine. _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ CONDITION OF CASE: ____EXCELLENT ____GOOD ____FAIR ____POOR Other Accessories included: (Neck strap, mouthpiece, lyre, etc.) __________________________________________________________________________________________________________________________________________________________________________ We agree to rent the above described school-owned instrument for the _____ school year. Yearly rental of $50.00 will be payable in full at the beginning of the school year or $25.00 at the beginning of each semester. We also agree that repair of any damage to the instrument beyond normal wear and tear shall be the responsibility of the person renting the instrument. CIRCLE ONE: PAYMENT INCLUDED PLEASE INVOICE _______________________________________ _____________________ Parent/Guardian Signature Date

_______________________________________ _____________________ Student’s Signature Date

_______________________________________ _____________________ Band Director Signature Date Office/School Use Only:

RENT PAID (DUE BY SEPT 15): $ _______________ DATE: __________________

RENT PAID (DUE BY JAN 15): $ _______________ DATE: __________________