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INDEPENDENT SCHOOL DISTRICT NO. 282 <br /> Community Services Department <br /> 3301 Silver Lake Rd • St. Anthony, MN 55418 9 Phone: 781-5021 <br /> Facilities Reservation Form Permit No. 7 4 <br /> Name Home Phone Bus. Phone�S�" <br /> y -1 /� /Co <br /> Address' �'��/%llfdxA; A� /,?- i Today's Date <br /> Name of Group or Organization <br /> Intended Use <br /> Date(s) wanted Day(s) Su M T W Th F. Sa (circle) <br /> 1 <br /> Building: ��77 <br /> High School °�( 3 Auditorium <br /> Community Center Cafeteria <br /> Wilshire P rk E m. School Classrooms) # <br /> Other Gymnasiu (If High School, circle one: <br /> • _ i`� '� LARGE SMALL ) <br /> Kitchen <br /> Other �= <br /> Doors to open am pm Expected attendance: J <br /> I <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 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 cla ms for <br /> potential damages incurred in this rental arrangement. f' I <br /> (signature of responsible person) <br /> v <br /> Bin to: <br /> (name) (address) <br />----------------------------------------------FOR OFFICE USE ONLY------------------------------------------------- <br /> ` r <br /> Class Ins Approved b /. �! 1 << / . <br /> PP Y i t Date f• ' �_ i <br /> Charges: Rental ' V_L y '• ' ' �t'�rj Custodial <br /> Cooks Other charges: S <br /> Note: <br /> WHITE—Community Services Office Copy CANARY—Business Office Copy PINK—Cuslodien■Copy GOLD—Applicant-s Copy <br />