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INDEPENDENT SCHOOL DISTRICT NO. 282 " 9T - <br /> community Services Department C3_ C)0�3 <br /> 3301 Silver Lake Rd • St. Anthony, MN 55418 •Phone: 781-5021 <br /> Facilities Reservation Form Permit No. <br /> Name t2A/?O L -J oo o-z-SJ-,d Home Phone 7k/- Sk'lj Bus. Phone <br /> Address �'7 ��' 3 /��z�rfi�z,tJ J` Date °Z `/ '7Z <br /> Name of Group or Organization A C "t) C. <br /> Intended Use tf)w! !A, y J621 c .✓!L W �l�r- r '�;�.L r.�r�7�f�' <br /> I <br /> Date(s) wanted /+�t� �/ 0�u�o cz 5 7 5 , 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 /> 601--r �p�L- 3 � Kitchen <br /> �4E1vTfLA L ,S/4'6 I- T'i✓ /L,, Other <br /> Doors to open am pm Expected attendance: '41U <br /> Activity begins am pm Admission: Free Charge <br /> Activity ends am 1t�Z)pm Will merchandise be sold? J <br /> Special arrangements needed (chairs, cooks. AV equipment, etc.): <br /> e-7-L f <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 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 /> Bill to: <br /> (name) (address) <br /> -----------------------------------------------FOR OFFICE USE ONLY--------------------------------------------- <br /> Class Ins Approved by Date i <br /> Charges: Rental Custodial <br /> Cooks Other charges: <br /> Note: <br /> WHITE—Community Services Office COPY CANARY—9uolneee Office COPY PINK—Custodians COPY OOLD—Apptkent'e COPY <br />