Wake County Public School System

I___________________________________________, accept full responsibility for

                                   (Parent)

__________________________, serial number_________________ and accessories

    (description of instrument)

(case, mouthpiece, bow, etc.) _________________________________ loaned from

                                                                     (please list)

Apex High School for the use of my child, _________________________________

                                                                                     (student’s name)

during the _____________________ school term. I understand that I am responsible for a

one-time, non refundable yearly fee of $____________.

I agree to care for the instrument and accessories as if they were my own and to pay for any
damage made necessary by misuse, negligence, or carelessness as determined by the school’s
Band Director.  Under no circumstance will I attempt to repair or have it repaired without
permission from the Band Director.

Student Signature______________________________________ Date______________

Address___________________________________________Phone________________

Parent/Guardian Signature_______________________________Date________________

Band Director Signature_________________________________Date________________