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INDEPEMONENT SCHOOL DISTRICT NO. 282 <br /> Community Services Department <br />} 3301 Silver Lake Rd • St. Anthony, MN 55418 • Phone: 781-5021 <br /> j • �/` Facilities Reservation Form Permit No. C/ <br /> Name Home Phone Bus. Phone <br /> Address �' /f7 -'v` ✓ !v��t� — ) — Date <br /> Name of Group or Organization <br /> Intended Use <br /> Da (circle) <br /> 3 Date(s) wanted y(s) Su M T W�`ft�F Sa <br /> r7..�ld:.�n• <br /> High School Auditorium <br /> Park View Community Center Cafeteria <br /> a Wilshire Park Elem. School 1� Classroom(s) b <br /> Other a y Gymnasium (If High School, circle one: <br /> - po+rir OLD NEW ) <br /> Kitchen <br /> T Other <br /> ::Dors to open am pm Expected attendance: <br /> i - <br /> Admission: Free Charge <br /> Ac;::i� • t � — —anl Will merchandise be sold? <br /> Special arrangements needed (chairs, cooks. AV equipment, etc.): <br /> I hereby cenif 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 4282. As a group or „rg=c.'.zational 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 k; r 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 /> 1 potential damages incurred in this rental arrangement. <br /> (signature of responsible person) <br /> Bill to: _ <br />.� (name) (address) <br /> __-------=--=-------•----------------------------FOR OFFICE USE ONLY----______--------- <br /> --- <br />` ,,� <br /> Class Ins ApNrovec! by ,H__../.-,r_�,�, � Date ,' � - <br /> r <br /> Charges: Rental ._� j" Custodial <br /> Cooks Other charges: <br /> Note: <br /> WHIT!—C.onununitr 3wvke.OMh+Copy CANARY—^ OMe*Copy PINK—CuNadlam Copy COLD—Applieenr a Copy <br />