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MOUNDS VIEW PUBLIC SCHOOLS RALPH R. R=- - ER COMMUN= CENTER <br />CONIMU ITY EDUCATION FACILITY RE-QuEsT <br />500 - 10TH STRECT NW <br />NEw BRIGHTON, MN 55112 <br />639-6221 *** FAX 639-6033 <br />REQ <br />J -, QR USFQFF I <br />.3 <br />Organization I rondQ�e B 2+ a) l As.SC,c-(scouts, arkJRc Church, Dist.Residents) <br />Facility Requestedn c, td -4—? Fac.Type rn m, Cha Classroom, etc. <br />TIME: Start �CwPM(circle one) End_ (rJ AM/t�circle one) <br />Individual DAY and DATE -(S): <br />Type of Activity:, ; n h 1, Ll GCLM c <br />Permit Bolder Deb Verdo rr t CC ►�T► I eC1 �S-�C-�'lE� <br />Activity Leader/Instructor if different from - <br />permit holder. <br />Address 2E�00 I nnsbi-uc.k _hr. <br />Phone- Work <br />Stet- .)u►,e.) <br />City 1\� . a <br />Home L3!c-1 1 FAX <br />Zip I I '�- <br />Special Requests (must be requested one (1) -,veek prior to activity). <br />('hairs Suri n -(Ctbl J..s�esf�Q r rr <br />Physical Education Needs <br />PRIORITY - School functions have priority over community activities. When it is necessary to intrude <br />on scheduled community activities, at least eight (8) days notice will be given and alternative facilities <br />arranged if possible. <br />Note - If arrangements must be changed or canceled, please contact the Community Education Office <br />at least one (1) week in advance of scheduled use. <br />I hereby certify that I am an agent of the above named organization .and have been <br />authorized to accept in their name the responsibility for observance of the rules and <br />regulations as stated in Policy/Regulations #1330 (on back) of the Board of Education as a <br />condition of the issuance of this permit. I understand that the permit for the use of school <br />facilities may be canceled if any of the rules are violated. <br />Signature`i ��.�C"?-C'''�.?'� Date <br />