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INDEPENDENT SCHOOL DISTRICT NO. 282
<br /> Community Services Department
<br /> 3301 Silver Lake Rd • St. Anthony, MN 55418 • Phone: 781-5021
<br /> Facilities Reservation Forml (��1�Lr7uLCNo� _
<br /> C'c,C����' �- �l ��� CGS•
<br /> Name R, Home Phone Bus. Phone 769,-
<br /> Address -. 2n ', '-L�L/ eC L,1K , ,A0, Date
<br /> Name of Group or Organization �/• /l � / T
<br /> Intended Use
<br /> Date(s) wanted Day(s) 9-u-.M T W Th.FSa., (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 /> l Kitchen
<br /> Other
<br /> O0 s oo en �d�l�am pm Expected attendance: •rte
<br /> Activity begins am pm Admission: Free Charge
<br /> Activity ends am pm 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 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 forgiving
<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 /> � I r
<br /> (sign uie,Pf resI56nsibie person)
<br /> Bill to:
<br /> (name) (address)
<br /> -----------SS------------------------------------ --
<br /> FOR OFFICE USE ONLY-------------------------------------- ------
<br /> ClaIns
<br /> IA
<br /> Approved by '�• Date
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