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INDEPENDENT SCHOOL DISTRICT NO, 282 <br /> Community Services Department <br /> 3301 Silver Lake Rd * St. Anthony, MN 55418 9 Phone: 781-5021 <br /> Facilities Reservation Form Permit No. <br /> Name ` ` Home Phone Bus. Phone <br /> Address :j Today's Date <br /> Name of Group orOrganization <br /> |ntundedUse <br /> ,�� <br /> Date(s) wanted Ooy<sX��wK4 T VV Th F Sm (circle) <br /> Building: <br /> —High School —Auditorium <br /> —Community Center —Cafeteria <br /> —Wilshire ) [� ] —Classroom(s) � <br /> -' ' ----- ---��� <br /> _��_O\hmr i i / c� �� �� —Gymnasium (|f High Schoo|, circle one: <br /> LARGE SMALL ) <br /> —Kitchen <br /> -_---O\her <br /> Doors!oopen ----__.anm _------pm Expected attendance: <br /> Activitybegino _---__-am pm Admission: —Free Charge <br /> Activity ends —am pm Will merchandise bosold? <br /> Special arrangements needed (chairs, 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 the responsibility for observance of the rules and regulations of the Board of Education, Independent School <br /> Diohict-#282.Ama group mr organizational agent,U will attend this function,and U will be solely responsible for giving <br /> any and all instructions to the custodians on other support personnel. Pnwswn1mtlqm'w0 this permit tm the custodian on <br /> duty im 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.Ren1ae waives all rights and claims for <br /> potential damages incurred in this rental arrangement. - <br /> (signature O'KresnnnubI6perspn) <br /> Bill to: - <br /> (name) (auun,,a) <br />_-__--_-_-__--_-----_--__---- FOR -~ <br /> Class -_- |nm -_.--- Approved by ' Date <br /> / <br /> Charges: Rental Custodial <br /> Cooks Otharchorgeo' <br /> WHITE-CornmunitylierWces Office Copy CANAAY-Business Otflc*Copy PINK-Custodians Copy GOLD-Applicanirs Copy <br /> ``. <br />