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�\V <br />MOUNDS VIEW PUBLIC SCHOOLS <br />COMMUNITY EDUCATION <br />RALPH R. Rrr•DER COMMUNrry CENTat <br />FACILITY Rr--Qu= <br />500 - 10TH STREET NW <br />NEw BRIGHTON, MN 55112 <br />639-6221 *** FAX 639-6033 <br />Organization I rondo e. �e+ H (Scouts, EEEChurch, Dist.Residents) <br />Facility Requested ?,Ly) , bar ' CIE leni. Fac.TypeC-_, v (r 5��2/w .3 ym a Classroom, etc. <br />L ■ *' � Lr-•� Kr <br />TIME-: Start 5;C)(-:) AM(M,circie one) End ; CC AM 'W(circle one) <br />Individual DAY and DATE(S) <br />MOR Nov. q. 9 . � ' q <br />Type of Activity: i5C(� kel i Dr cti ce S - <br />Permit Holder Deb Verd ocr rz B Ccr 1 CLnch- c <br />Activity Leader/Instructor if different from <br />permit holder. <br />Address 2.aco I rnnsbruc-k 1)r. <br />City �,f • g Zip 551 1 -L <br />Phone: Work 5 C --,L — 4 5_40 0 Home_ (c`3(c— 1 S3 1 FAX <br />s<Pt- ju„e.) <br />Speciil Requests (must he requested one (1) .veek prior to activity). <br />:�1� ' u::l ; ::' !:: •t' ('!3 irk <br />Physical Education Needs <br />Other <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 perm.at. I understand that the permit for the use of school <br />facilities may be canceled if any of the rules are violated. <br />. 7 <br />Signature - Date <br />,q v <br />