District 11 Music Instrument Use Permit #1234-C (modified)                                                                  Colorado Springs School District 11                                  
Dr. Michael J. Thomas, Superintendent                                                                                                                    
Karol Gates, Director of Curriculum & Instruction                                                                                              
Laurilea McDaniel, Visual & Performing Arts Facilitator                                                                                                                     Katherine Kennedy, Teacher
Sign in to Google to save your progress. Learn more
STUDENT'S NAME *
SCHOOL / CLASS *
What instrument?
PARENT/GUARDIAN'S NAME *
PARENT/GUARDIAN'S EMAIL ADDRESS *
ADDRESS *
PHONE NUMBER *
I understand that the teacher, and  School District 11 will keep a record of the instrument that is checked out to my child, it's serial number and VAPA number,  using the Destiny check out system and it's replacement cost, available to me at all times in the Destiny system. *
Required
I agree to bear full responsibility for payment of the non-refundable $20 usage fee for student's usage of a School District 11 instrument. (The fee can be turned in to the office or to Mrs. Kennedy.) *
Required
I agree to bear full responsibility for the prompt return of the aforementioned School District 11 instrument; upon the due date specified, upon demand by the teacher in charge for whatever reason, should the student discontinue their participation in the District 11 Instrumental Music Program. *
Required
I agree to bear full responsibility to see that the aforementioned instrument IS NOT LEFT UNATTENDED WHERE IT MAY BE STOLEN OR DAMAGED, THEREBY, RESULTING IN THE FOLLOWING ACTION: A. Replacement of the aforementioned instrument by paying the amount of declared value to School District 11 if said instrument is stolen, or damaged beyond repair (repair is more than the instrument's worth). B. Payment of the cost of repair, in full, if said instrument is damaged beyond normal usage wear. C. Payment of cost to reinstate VAPA# tag in the event that the tag is damaged or removed ($20.00) *
I agree to bear full responsibility to contact the teacher in charge BEFORE taking the instrument described above for repair. This will inform the teacher in charge as to why said instrument is not in use and will allow the teacher to direct the instrument repair. *
Parent/Guardian - I understand that by signing electronically below, I have read the foregoing and agree to abide by the rules and regulations as set forth herein while my student is being granted use of the District 11 owned instrument described above. If the above instrument is not returned within 5 working days of the due date, teacher request, or discontinuing the program, a theft report will be filed with the Colorado Spring Police Department. *
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Colorado Springs School District 11. Report Abuse
Google Forms