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ANDEPENDENT SCHOOL DISTRICT N0.282 <br /> Community Services Department <br /> '3301 Silver Lake Rd• St. Anthony, MN 55418 • Phone: 781-5021 <br /> • Facilities Reservation Form Permit No. _Q.,�Y_ • <br /> Name ` ���- �/�/J,/z'. .X_ Home Phone /A� 5 9 Bus. Phone ��-s�`���� <br /> Address jya'y �3���y� /✓/= Date <br /> Name of Group or Organization <br /> Intended Use <br /> Date(s) wanted J�� OT T Day(s) Su M T W Th F ®(circle) o <br /> Building: <br /> 9 <br /> High School Auditorium 1 <br /> Park View Community Center Cafeteria I <br /> Wilshire Park Elem. School Classroom(s) # <br /> _Other T.0 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 2, pm Admission: Free Charge j <br /> •tivity ends am _& pm Will merchandise be sold? <br /> i <br /> x Special arrangements needed (chairs. cooks. AV equipment, etc.): <br /> �i <br /> I� <br /> 1 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,l 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 responsi person) <br /> Bill to: <br /> (name) (address) <br />---------------------------------------------FOR OFFICE USE ONLY------ -------------- -----�-- <br /> Class Ins Approved by , Date 1 Sr <br /> i <br /> arges: Rental Custodial <br /> Cooks Other charges: <br /> Note: <br /> WMT!—Coomelty 8 le.e OMeo CWr CANARY—Suehuee OIIIeo Copy PINK—Cuotoaar Copy GOLD—Appllgnt'o copy <br />