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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 Form Permit No64�7/. <br /> C, •Name Sil rt L cY�/1cz_/fi, Home Phone Bus. Phone �— <br /> Address 3,300 Today's Date <br /> Name of Group or Organization 6C Jn i 1%. <br /> Intended Use ���[i C <br /> Date(s) wanted / / T /�� Day(s) Su M T W TF F Sa (circle) <br /> Building: <br /> High School Auditorium <br /> Community Center Cafeteria <br /> Wilshire Park Elem. School Classroom(s) # <br /> Other Gymnasium (If High School, circle one: <br /> Y LARGE SMALL ) <br /> �J Kitchen <br /> Other <br /> Doors to open am pm Expected attendance: <br /> Activity begins aQ 0am pm Admission: Free Charge <br /> Activity ends am m 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 claims for <br /> potential damages incurred in this rental arrangement. <br /> � .. r�. <br /> (signature of responsible person) <br /> Bill to: <br /> (name) (address) <br />-----------------------------------------------FOR FFICE USE ON ----------------------------------------------- <br /> Class Ins Approved b r c e <br /> Charges: Rental 0,11 Custodial <br /> Cooks Other charg • <br /> Note: <br /> i <br /> WHITE—Community Services Ofllos Copy CANARY—Business Office Copy PINK—Custodians Copy GOLD—Applicant's Copy <br />