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MOUNDS VIEW PUBLIC SCHOOLS RALPH R. RFS=Drat COMMUNITY CENTER <br />COMMUNITY EDUCATION FACILITY RI;Qu= <br />500 - 10TH ST -ET NW <br />NEw BRIGHTON, MN 55112 <br />639-6221 *** FAX 639-6033 <br />Organization I rondo 2 8 e+� � � .(Scouts, ark Church, Dist.Residents) <br />Facility Requested Eaaewwd hdd[ Fac.Type G ►r, G xn, Cafe, Classroom, etc. <br />1;2 00 xpn! <br />TIME: Start 'i:O (L IPM(circle one) End AMI&M (circle one) <br />Individual DRAY and DATE(S): <br />tlr"" <br />1'ype of Activity: [ <br />S a+u rd n t.l S Nov. 2 1 j q la +-C <br />Permit HolderDeb Ve-rdG rig BA- Cert -�I ed CC111C-be-C <br />Activity Leader/Instructor if different from <br />permit holder. <br />Address 2aCO 1 nnSh uC_[C br. City <br />�4.E <br />Phone: Work 5S6-45-40 Home k3(G-153 1 FAX <br />stP -- .1ut,e.) <br />Special Requests (misst he requested one (1) <br />.Udio <br />Physical Education Needs <br />Zip 5�5- 11 -�- <br />Nveek prior to activity). S►pecta1�r w <br />:`''.•� 7 r'I,:,7,<_but-e-Tabl���ia+.LrChairs <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 cliauged 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 />7a./uo <br />Date 7/ Z(? <br />/3 <br />ell 711': 5"Y <br />