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INDEPENDENT SCHOOL DISTRICT NO. 282 <br /> w <br /> Community Services Department <br /> 3301 Silver Lake Rd a St. Anthony, MN 55418 o Rhone: 781-5021 <br /> Facilities Reservation Form Permit No.d <br /> Name rii /3-'c'=, Home Phone j'�3/J us. Phone -3✓ <br /> Address 5.7 Date <br /> Name Or GrOuF or OfvanjL6tiJf1 <br /> Intended Use <br /> Date(s) wanted �-�� - Day(s) Su M T W Th Sa (circle) <br /> Building: <br /> High School Auditorium <br /> P6•k View Community Center Cafeteria <br /> Wilshire Park Elem. School / —Classroom(s) <br /> �—Other �'�-r. �'I- fat VI f�•J- Gymnasium (If High School. circle one: <br /> OLD NEW ) <br /> Kitchen <br /> Other <br /> Doors to op en —a.-r. —pm Expected attendance: <br /> Actwi!y.beg!ns am�-n.pm Admission: Free Charge <br /> A-.tvvity ens am Will merchandise be sold? <br /> Special arrangements needed (chairs, cooks, AV equipment. etc.): <br /> I hereby certify tr-Et I am a:, agent of the above named oroup or organization and am authorized to accept in their <br /> name the resaonsibiiity for observance of the rules and re?uiations of the Board of Education, Independent School <br /> District #282. As a group or organizations: 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 accepting this arrangement. rentee agrees to hold harmless <br /> I.S.D. 282 and its representatives from ail claims incurred in use of the facility. Rentee waives all rights and claims for <br /> potentiai damaaes incurred in this rental arrangement. <br /> (s+On9!u:e Of respons:bie person) <br /> Biil t0: <br /> ;nar'ne! (&Ooress) <br /> -----------------------------------------------FOR OFFICE USE ONLY----------------------------------------------- <br /> Cass Ins Approved b -��_-t-G-TIC- <br /> Pp Y �-- � Date UZ <br /> Charoes: Rental �b� i Custodial <br /> Cooks Other charges: <br /> Note: <br /> Now <br />