Video Equipment Check-Out Form

DIRECTIONS:  To check out equipment, you MUST fill out the ENG Equipment Checkout Form.  The bottom portion MUST be filled out completely.  The teacher MUST double check your check-out form and the bag before leaving the room and upon bringing it back.  Do not unpack a bag yourself before it is checked.  The equipment is checked out and returned properly to protect you. 

____    Camera:   Circle one:    Canon GL1    or    Panasonic PV-Gs 500

____    Tripod: Circle one    Bogen    or    Manfrotto    or    Other    ________

____    Tripod Head (Make sure it’s secured back on the tripod upon return)  

____    Camera Battery  (Write number of batteries taken in space provided)

____    Battery charger/Power adapter

____    Camera Coupler (goes to battery charger/power adapter for dc power)

____    Microphone

____    XLR Cable

____    TV mic flag  

____    Headset to listen to audio  

____    Camera Light

____    Extension Cord

____    Power Strip

____    Camera Bag  

____    Mini DV Tape(s) Take more than you will need.  List # of tapes on

            space provided & U - used or N - new

____    Video Proposal of News Package for reference

____    Interview Questions

____    Log Sheet, Note Pad & Pen/Pencil to write down facts & names (which

            should also be recorded on tape)

____    Other: ________________________________

I agree to the following:

• Equipment checked off above is to be used only for the event stated below.
• Equipment must not be left in the cold/hot weather overnight or for any extended length of time.
• If anything happens to the equipment while signed out to me, I will report it in the space below upon returning it back to the school.
• The equipment MUST be returned BEFORE homeroom at 7:25 a.m. tomorrow or at 7:25 a.m. upon the return to school after a weekend or a holiday.

• 1st offense: You get no equipment for 2 weeks.

• 2nd offense: You get no equipment for 4 weeks.

• 3rd offense: You never get to check out equipment again. You're stuck in the studio for the rest of the year.
   

PICK-UP DATE AND TIME __________________________

RETURN DATE AND TIME __________________________

Event or need for equipment (if sporting event, specify opposing team’s name here also): __________________________________________________________________________

 
My son/daughter would like to check out video equipment from the Television Studio. Specific pieces of equipment are listed above. I understand the equipment will be inspected before it leaves and after it returns to assure it is brought back in the same condition as it was when it was checked out. I agree to be financially responsible for the repair to/replacement of the equipment if it is damaged while checked out by my
son/daughter.

Student Signature___________________________

Parent Signature_________________________

Teacher’s Signature after return of equipment: __________________________

• List below any problems/concerns you had with the equipment:

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