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INDEPENDENT SCHOOLOISTR1CT NOD. 282 !- <br /> Community SQrvlc4V*j xldrrient <br /> t t 3301 Silver Lake Rd • St. Anihony, 11110 =5"19 r Phorre: 791.5021 <br /> 4 <br /> Facilities Reset'Villllon Form," <br /> orm Permit No. <br /> Name Home Phone !j �'�-'X14 bus. Phone `%-� t I• <br /> Address <br /> r Date t_ i <br /> Name of Group or Organization ~I 1 -���%: "s l i�C1 " i�,�?r'Tr';r d "? �;bl J. I t- r �.:� ►" ',� <br /> F <br /> Intended Use <br /> Date(s) wanted `< <- ... (`'' ' Da (s)t, M T W Th F Sa ) <br /> y �� (circle) <br /> Building: <br /> High School Auditorium <br /> Park View Community Center Cafeteria <br /> Wilshire Park Elem. School Classrooms) # <br /> Other *f i '� Gymnasium (If High School, circle one: <br /> OLD NEW ) <br /> Kitchen <br /> Other <br /> Doors to open ! am pm Expected attendance: <br /> i <br /> Activity begins am pm Admission: Free Charge <br /> Activity ends am pm Will merchandise be sold? <br /> Special arrangements needed (chairs, cooks, AV equipment, etc.): _ • <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, Ind pendent School <br /> Distrint #282. As a group or organizational agent,I will attend this function,and 1 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 waives all rights and claims for <br /> potential damages incurred in this rental arrangement. Yf <br /> ' S�I J •,ti �: Imo'/s ...°tf I ��,. .I <br /> ( (signature of responsioe person) <br /> Bill to: <br /> (name) (address) <br /> --------------------------------------------FOR OFFICE USE ONLY---—--------------------------«------------- <br /> Class Ins Approved by Date <br /> Charges: Rental Custodial <br /> Cooks Other charges: • <br /> Note: <br /> WWI—CoaimurMy 9 Mr1wa Office Copp CANARY—tlNdam Me*Caper PINK—C s"Ime Con DOW—ApplkanY Copy <br />