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0��' <br />L4 da4f x /9 A�� x I AO __ e:2_1�- S- .'Aw <br />MOUNDS VIEW PUBLIC SCHOOLS RALPH R_ REI -;DER COMMUNITY CENTER <br />COMMUNITY EDUCATION FACILITY Rr--Qu=- <br />500 - IOTH STRL-ET NW <br />NEv BRIGHTON, MN 55112 <br />639-6221 *** FAX 639-6033 <br />REQMT R USE OF FACILUMS <br />Organization rOndQ(e Ske+baS(Scouts, arklRe Church, Dist.Residents) <br />Facility Requested ECJPAVCCQ Fac.Type rY1 Gym, Cafe, Classroom, etc. <br />1I <br />TIME: Start S.GG AM/&circle one) End q,11 Go AM 'M circle one) <br />Individual DAY and DATE(S): J k Q n Sepi' ,Z, S q4 S — Mar S <br />Tues a <br />!` � r� <br />M Thur " �� '� t iDip Fr; 1,21 <br />_, - <br />Type of Activity: I RA EaS kp_- 1b i I 1 r a C� - <br />I'ernlit Holder'b UerdG r>rt Cer-T i TI eC� Cc(]Che!e <br />Activity Leader/Instructor if different from <br />permit holder. <br />Address 28 CC I nnsb uck r. City <br />Phonc Work 5 �; L - LL 5 4C Home kc,3(G- 153 1 FAX <br />_5<Pt- .lucre) <br />Special Requests (must be requested one (1) week prior to activity). <br />.flit; ` ,.:'J:il 1`ti`';. ,''. l'�l:rir• <br />Pliysical Education Needs <br />Zip 55-11 '�_ <br />Other��.�. >`(e <br />CCC CLS. I Wall drvraer <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 <br />b <br />Date 71-519 's <br />