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Communlry aervrcua vbNm�unarm. <br /> 3301 Silver lake Rd c St. Anthony, MN 55418 a Phone: 781-5021 <br /> Facllities Rese'NMIon Form Permit No. <br /> Name _ - t ) �__�D�l v� uY� Home Phone 76 r Bus. Phoneg`� <br /> Address /VE Date r / (S/ M7_ <br /> Name of Group or Organization i L�--� <br /> :j7V t7 <br /> Intended UseF-ft / <br /> Date(s) wanted Day(s)6u M T W Th F Sa (circle) <br /> Building. <br /> High School Auditorium <br /> Park View Community Center Cafeteria <br /> Wilshir P rk Elem. School Classroom(s) # <br /> Other - 1�1r Pore+ Pk Gymnasium of High School, circle one: <br /> OLD NEW ) <br /> Kitchen <br /> Other _ <br /> Doors to open am pm Expected attendance: 5� - <br /> Activity begins —//,"'Oam pm Admission: Free Charge <br /> Activity ends am f f pm Will merchandise//be sold? U ZI / <br /> a 4r 1^ A C/I el 10n <br /> • Special arrangements needed (chairs, cooks. AV equipment, etc.): —��a <br /> t!L�Jy M i'le tk/W c G <br /> I hereby certify that I am an agent of the above named group or organization and am authorized to accept in their <br /> name the responsibility for observance of the rules and regulations of the Board of Education, Independent School <br /> District #282. As a group or organizational agent, I will attend this function,and I will be solely responsible for giving <br /> any and all instructions to the custodians or other support personnel.Presentation of this permit to the custodian on <br /> duty is necessary for admittance for the initial date. In accepting this arrangement, rentee agrees to hold harmless <br /> I.S.D. 282 and its representatives from all claims incurred in use of the facility. Rentee wai es all rights and claims for <br /> potential damages incurred in this rental arrangement. <br /> (Sign/.re of responsible person) <br /> Bill to: <br /> (name): (address) <br /> ---------------- <br /> FOR OFFICE USE ONLY----------------------------------------------- <br /> S /--lifer= � — Date <br /> Class Ins — Approved by <br /> Charges: Rental __ ___ Custodial <br /> Cooks --- Other charges: <br /> • Note: — — <br /> YYNITE—CommurJIV 6anlcee OIIIct COPY CANARY—Budnoee OHIcs Copy PINK— Co IOCAam Copy -GOLD—Appiku Ve Cop{ <br />