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INDEPENDENT SCHOOL DISTRICT NO. 282 <br /> Community Services Department <br /> 3301 Sllyer Lake Rd • St. Anthony, MN 55418 • Phone: 781-5021 <br /> Facilities Reservation Form Permit No. <br /> 1-77 _ �7 - <br /> • Name f ,?r ��f�l,�� � Home Phone -� } Bus. Phone <br /> Address ' no Date <br /> t <br /> Name of Group or Organization <br /> intended Use 777 <br /> uc l a&n-Da;eisi wanted Day( SIX T W Th F Sa (circle) <br /> Buiid ng: <br /> High School Auditorium <br /> Park View Community Center Cafeteria <br /> Wilshire ark Elem. Schnnl t Classroorn(s) # <br /> O;her !!OZj 'rit ;' �ZV �/ l�-1`.� Gymnasium (If High School, circle one: <br /> OLD rq=�W ) <br /> Kitchen <br /> Other <br /> Doors to open an-. pm Expected attendance: <br /> activity begins i� 3 am pm Admission: Free Cnarge <br /> _ Activoy ends am 0 -2 0pm Will-merchandise be sold? <br /> • Special arrangements neeaed (cnairs. cooks. AV equipment. etc.): <br /> 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, 1 will attend this function, and 1 will be solely responsible for glying <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 hoid 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. / <br /> (Sig.w6re of espons!We person) <br /> Bill lo: <br /> (name! (aaaress) <br /> ----------------------------------------------FOR OFFIC�,�.J�SE`ONLY <br /> Class Ins Approved by -i`"'" =' � Date <br /> 7Chardes: Rental ,T°� �` `=Custodiat - <br /> • Cooks Other charges: <br /> Note: <br /> rNrr[—Cen mwWtj Services omee Corr CANARY- eurnep ohlu Copy PINK-Cwlemam Copy GOLD-Apprrranr.Copt <br />