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• J <br /> INDE,PEN®EST° SCHOOL DISTRICT NO.:Z.g2 <br /> Community Services Department <br /> 3301 Silver Lake Rd m St.'Arithony, MN 55418 a Phone: 781-5021 <br /> Facilities Reservation Form Permit No. <br /> Name Home Phone /U/ v 2Elus. Phone . <br /> Address � �2 Date <br /> Name of Group or Organi I n ��7/j;f o <br /> Intended Use SCI L <br /> Date(s) wanted K Day(s) Su M T W Th F Sa (circle) <br /> Building: <br /> High School Auditorium <br /> Park View Community Center Cafeteria <br /> Wilshire Park Elem. School Classrooms) # <br /> Other Gymnasium (If High School, circle one: <br /> OLD NEW ) <br /> Kitchen <br /> Other <br /> Doors to open am pm Expected attendance: <br /> Activity begins am 5 pm Admission: Free Charge <br /> Activity ends am�a✓�pm Will merchandise be sold? <br /> Special arrangements needed (chairs, cooks, AV equipment, etc.): /L��� /i°�����/`t- �� • <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. Pres ntation of this permit to the custodian on <br /> duty is necessary for admittance for the initial date. In accepting this ar ag6ement, re tee agrees to hold harmless <br /> I.S.D. 282 and its representatives from all claims incurred in use of the f clli y. Rente w ves all rights and claims for <br /> potential damages incurred in this rental arrangement. <br /> k <br /> (signatur dot, esponsible person) <br /> Bill to:_ <br /> (name) (address) <br /> ---------- ---- -FOR OFFICE USE ONLY——--------------------------------------------- <br /> Class. Ins Approved by 4; i ce Date 0 7 <br /> Charges: Rental —�/��/ �� Custodial <br /> Cooks Other charges: <br /> Jote: <br /> WHITE—Community Services office Copy CANARY—Buolnn•.^• !pr oiKK— Cu-t. lone Corr GOLC. inoflcant'o Copy <br />