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INDEPENDENT SCHOOL DISTRICT NO. 282 dw <br /> Community Services Department <br /> 3301 Silver Lake Rd • St. Anthony, MN 55418 • Phone: 781-5021 <br /> Facilities Reservation Form Permit No. LLL_ <br /> Name 2.&L4:� QL Home Phone -)t/ -) /4`Bus. Phone <br /> Address 3 D n / - �4 �.. �� -/�- l� • <br /> Date <br /> / n <br /> Name of Group or Organization e4 A 4 A-111 <br /> Intended Use - <br /> Date(s) wanted /,/ - Day(s)P M T W Th F Sa (circle) <br /> Building: <br /> High School Auditorium <br /> Park View Community Center Cafeteria <br /> Wilshire Park El S I / Classroom(s) # <br /> Other -�/1a, - ��'�L,, 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 _pm Admission: Free Charge <br /> Activity ends am pm Will merchandise be sold? :a 1 <br /> Special a-rangements 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, 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 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. <br /> dL <br /> � <br /> (signature of responsible person) <br /> Bill to: <br /> (name) (address) <br /> -------------------------------------r------FOR OFFICE USE ONLY------------------------ ------ <br /> Class Ins Approved by A Date <br /> Charges: Rental Custodial <br /> Cooks Other charges: -«"' <br /> Note: <br /> Meats-aow..+h a«.r..Gfftw corn CAwurT-&A&ftr Dew coA PINX-CwMDdr eeor GOLD-aooftsrti coot <br />