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MOUNDS VIEW PUBLIC SCHOOLS RALPH R. Rr-rmr-st COMMUHmr CENTat <br />COMMUNITY EDUCATION FACILITY REQussr <br />500 - 1 Orta STREET NW <br />NEw BRIGHTON, MN 55112 <br />639-6221 * * * FAX 639-6033 <br />RF UL1 T MR U E QF FACJLITMS <br />Organization I rondo le. Baas e.+ba) I kSQC.(Scouts, ar1JRe Church, Dist.Residents) <br />Facility Requested n rl �Fac.Type Cnt;7 y� J Classroom, etc. <br />J <br />TIME: Start , Do AM/ Ivl(icircle one) End aj 00 AM('M kcircle one) <br />Individual DAY and DATE(S)- <br />1 of Activity: '�q�� � Q � � Pr �� 7 c p.) - - - <br />Permit Holder Deb �'erdo�ra , I Cerr �'�- <br />J eel <br />Activity Leader/Instructor if different from <br />Permit holder. <br />Address 2aoo I nnsbruck. r• City I4. 8 . Zip 55-11 --�_ <br />Phone: Work 5 C -b r 4 ; 4 <br />7�tPr- Ju►,e.) <br />Home (c.•3 -_1J �_ FAX <br />Special Requests (must he requested one (1) week prior to activity). <br />...Alli `..i'•1::i �:'`'::. t'. �li:!i,: <br />Physical Education Needs Other _e <br />r <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 />ILI Signature _Date %/ 1,519'Z <br />L4 o(a"a X IF "�4 <br />