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:`INDEPENDENT-SCHOOL DISTRICT NO. 282- <br /> Community ServWes Department <br /> 3301 Silver lake Rd a SL Anthony, MN SS418 a Phone: 781.5021 <br /> or Facilities Reservation Form Permit No. .Q>r. <br /> NameOIf1f12nvv <br /> � Ls,flcM (Home Phone Bus. Phone <br /> Address - 2 ��� � �-�lTsl'�A&) " 'Cyt4�M1io� sslapate ...(oil <br /> Name of Group or Organization �r� 1i S C [�►'k/' /V� �lot`�t �1 1 uet '�^_ <br /> Intended Use lr ` ��y.ti.r"►�i " <br /> Date(s) wanted / `�`tl '" �•� Day( Su M T W Th Fe (Circle) <br /> Building: <br /> Nigh School Auditorium <br /> Park View Community Center Cafeteria <br /> Wilshire Park Ele . Sch i Classroom(s) 0 <br /> Other .{�„s . . GV. � Gymnasium (If High School. circle one: <br /> OLD NEW ) <br /> Kitchen <br /> Other <br /> Doors to open $am pm Expected attendance: tuAs <br /> Activity De-ins IQ _pm Admission: _ Free _Charge <br /> �ctivity ends am ---I---Pm Will merchandise b io <br /> Special arrangements needed ,cnaifs. 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 One responsibility for observance of the rules and regulations of the Board of Education. Independent School <br /> District 0282. As a group or organizational agent,l will attend this function.and 1 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 facility.Rentee Ives all rights and claims for <br /> potential damages incurred in this rental arrangement. <br /> (signature of respon is person) <br /> Bill t0: C< d21i:.� a.� C.Qi'Jlf'�� (YL� <br /> (name! (awn") • <br /> ------NN--NN----�----------------- • NMI• <br /> FOR OFFICE USE ONLY _ <br /> Class Ins Approved by y•��'- Date <br /> •Charges: Rental Custodial <br /> Cooks Other charges: <br /> Mote. <br />' •• MNII!—CAM"hWq aaae•.ON"C4" CAKMT—&AMON ON"Ca" 01*9—CwbAkw CMr GM0—Aprrwnf.CM <br />