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INDEPENDENT SCHOOL NO-282- <br /> Community Services Department <br /> 3301 Silver Lake Rd a St. Anthony, MN 55418 o Phone: 781=5021 <br /> Facilities Reservation Form Permit No. <br /> Name '� Home.Phone 'T 1 us. Phone Sv'3 jC <br /> Address -�!4!�U �r_�b_ILCCt ti� —_ Date <br /> Name-of Group.or Organization <br /> Intended Use Cu y <br /> Date(s) wanted C2 Day(s) Su M T W Th F a (circle) <br /> Building: <br /> High School Auditorium <br /> Park View Community Center Cafeteria <br /> Wilshire Park Elem. Sc}ool 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 60 am _ pm Admission: Free Charge <br /> Activity ends am wpm 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 theirules 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 <br /> 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. R ntee waives all rights and claims for <br /> potential damages incurred in this rental arrangement. <br /> UIV(signature of responsible person) <br /> Bill to: <br /> (name) (address) <br /> FOR OFFICE USE ONLY ------------------------------------ <br /> Class -1� . Ins Approved by Date <br /> Charges: Rental 1� - �–� � Custodial <br /> Cooks Other charges: <br /> Note: <br /> WHITE—Community Sorvlceo office Copy CANAL Buoinoee Office Copy PINK—Cuotodiam Copy GOLD—Appliconi's r ppy <br />