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INDEPENDENT SCHOOL DISTRICT NO. 282 <br /> Community SerNoes Department <br /> 3301 Silver Lake Rd • St. Anthony, MN 55418 a Phone: 781-5021 _ <br /> Facilities Reservation Form Permit No. • <br /> Name �= ``� -� -� Home Phone -"'Y'r- Gy Bus. Phone �! �- <br /> Address �' �' L �` Date :Z// I <br /> Name of Group or Organization �"�1 ►� 't` -' �. ' ' <br /> Intended Use )') ! ' C • 4r - - <br /> Date(s) wanted r 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 Classroom(s) # <br /> Other 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 pm Admission: Free Charge <br /> Activity ends am pm Will merchandise be sold? <br /> Special arrangements needed (chairs, cooks, AV equipment, etc.): • <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, 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 /> (signature of responsible person) <br /> i <br /> Bill to: „ `� 7' <br /> (name) (address) <br />______ OFFICE USE ONLY ------------------ <br /> Class Ins Approved by Date <br /> Charges: Rental Ad Custodial <br /> Cooks Other charges: '• <br /> Note: <br /> Mmrra—oom wrwr ftrokw oM1w coos CAMMV—&NIM"Ofte coot' roar—Qwtoftm caoy 00W—anoftmmr+COW <br />