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MOUNDS VIEW PUBLIC SCHOOLS RAUH R. REEDER Cots MUNrrY CENTER <br />COMMUNITY EDUCATION FAciL rry REQu= <br />500 -10TH STREET NW <br />NEw BRIGHTON, MN 55112 <br />639-6221 *** FAX 639-6033 <br />Organization I non d o e BL+b2ll Assa;(Scouts'IEE3 Church, Dist.Residents) <br />t <br />Facility Requested r� �� CCS Ie-Fac.Type rn C Z 7 Cafe` Classroom, etc. <br />r <br />TIME: Start1g- (PPM(circle one) End J C,', CC AMI'M✓(circle one) <br />Individual DAY and DATE(S): <br />Type of Activity: 1 r�_;Slot JDCil S l Curin a �� e 1')"�' <br />Permit Holder Deb Verdoora I BE 1. Cir- ,'-�-i ed Conches <br />Activity Leader/Instructor if different from <br />permit holder. <br />Address 212�Oo I n n s bru c.k r • City , 8 , Zip 551 1 �2-_ <br />Phone: Work SS 6 — 45'40 <br />scpt- Juke) <br />Home L36- I S-3 I FAX <br />Special Requests (must be requested one (1) week prior to activity). <br />T -:Y' -s & Chairs, Sca►in_Table S P awC-Ma,r <br />Physical Education Needs Other s [wc6sk-- <br />S (_o re_boc' AT <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 facili.tics <br />arranged if possible. <br />Note - If anangcments must be cbanged 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 responsibUity 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 />vV <br />Date 7//3 L9 � <br />