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Y <br /> INDEPENDENT SCHOOL DISTRICT NO. 282 ' <br /> Community Services Department <br /> 3301 Silver Lake Rd • St. Anthony, MN 55418 • Phone: 781-5021 <br /> Facilities Reservation Form Permit No. <br /> Name T;,, �''� 1 �. Home Phone 2:&H , Bus. Phone '- <br /> I <br /> Address Date M) <br /> Name of Group or Organization <br /> Intended Use 1-I )I ti <br /> Date(s) wanted ' '' 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 /> /• --II� Other <br /> Doors to open am pm Expected attendance: <br /> Activity begins am wpm Admission: Free Charge <br /> Activity ends am pm Will merchandise be sold? 1 <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 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 /> (signature of responsible person) <br /> Bill to: <br /> (name) (address) <br /> -----------------------------------------------FOR OFFICE USE ONLY------------------------------------------------ <br /> Class Ins Approved bye. Date <br /> Charges: Rental r `/ Custodial <br /> Cooks Other charges: <br /> r � <br /> Note: t- r r_...i� • �•'� '� <br /> r <br /> WHITE—Community Services Office Coov CANARY—SUSIMSrr Otft@ Coor PINK—Custodians Coov GOLD—AodlunPs Coov <br />