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• O.r•r•_• b•.Y•Ir•. • %0'VOOVVa• 60OUI6 f10V4 IV We 46W496 <br /> Community Services Department <br /> 3301 Sllirifr Lake Rd a St. Anthony.MN 55418 is Phone:781-5021 <br /> . FacillUes Reservation Form Permit No. <br /> • _ <br /> Name Home Phone e <br /> Bus. Phon <br /> Address D Date I A 14 <br /> Name,ol Group or Organization <br /> Intended Use <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) ft <br /> Other Gymnasium (If High School. circle one: <br /> Kitchen OLD NEW ) <br /> Other <br /> Doors to open am pm Expected attendance: <br /> Activity beginslu-IJ7%am ?:n 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 1 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-cr-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 responsi0 'son) <br /> Bill to: <br /> !name) (address) <br /> •---------------------------------------------FOR OFFICE SE ONLY�..�___�_____._�_.. <br /> Class Ins Approved by Date <br /> Charges: Rental Custodial <br /> Cooks Other charges: ' <br /> • <br /> Note: <br /> wNA!�lewuwu•M►t�.niew dlie.Cew ��IUM—ewe...•Oil1c•Errr OIMR�GwrN�w Pw� eel0��f11 OMO <br />