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INDEPEN DENT SCHOOL DISTRICT MO. 282 Community Services Department I 3301 Silver Lake Rd o St. Anthony, MN 55418 • Phone: 781-5021 Facilities Reservation Form Permit No. Name [ASS 0IY�J tTA � �� )Home Phoneioo �3 v Bus. Phone • Address 3311 rr( FLn �j Date Name of Group or Organization �S , Intended Use ?%C'K3 C' l��l !(Sf Date(s) wanted _�___ p�J Day(s Su)M T W Th F Sa (circle) Building: High School Auditorium `- Park View Community Center Cafeteria Wilshire Park Elem. Schh I Classroom(s) )t —.e Other Gymnasium (If High School, circle one: j, OLD NEW ) Kitchen Other Doors to open am pm Expected attendance: Activity begins am NU��pm Admission: Free Charge ' Activity ends am T" )()pm Will merchandise be sold? &^,.4fe- Special arrangements needed (chairs. cooks. AV equipment; etc.): .I I hereby certify that I am an agent of the above named group or organization and am authorized to accept in their name the responsibility for observance of the rules and regulations of the Board of Education, Independent School District #282. As a group or organizational agent, I will attend this function,and I will be solely responsible for giving any and all instructions to the custodians or other support personnel. Presentation of this permit to the custodian on duty is necessary for admittance for the initial date. In accepting this arrangement, rentee agrees to hold harmless I.S.D. 282 and its representatives from all claims incurred in use of the facility. Rentee waives all rights and claims for potential damages incurred in this rental arrangement. r (signature of responsible person) Bill to: (name) (address) FOR OFFIC USE ONLY -;------------------------------------------ `-� --------------------- ---------- --------- Class Ins / Approved by Date Charges: Rental Custodial -j Cooks Other charges: Note: ' 1 ' I I WHITE—Community 801141tas OfRca Copy CANARY—9usiroes Office Copy PINK—Cusfodions Copy GOLD—Applicant's Copy