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INDEPENDENT SCHOOL DISTRICT NO. 282 <br /> Community Services Department <br /> 3301 Silver Lake Rd • St. Anthony, MN 55418 *.Phone: 781-5021 <br /> Facilities Reservation Form Permit No. =r <br /> Name t��. :^ �C, -� � �-� Home Phone 1��- °`•�"-Bus. Phone - -- <br /> Address 21 ' Date <br /> Name of Group or Organization <br /> Intended-Use lj�Q v <br /> Date(s) wanted 14 f r 1-- Day(s)r SLt%.M T W Th F Sa (circle) <br /> Building:. - <br /> High_Sc6gol Auditorium <br /> Park View Community Center Cafeteria <br /> Wilshire Park Elem. School Classrooms) # <br /> �' ,f �-.� - Gymnasium If High School, circle one: <br /> OLD NEW ) <br /> L :<-' U` ' Kitchen <br /> Other <br /> Doors tobpefi,'- am pm Expected attendance: �S <br /> Activity liegins� am pm Admission: Free ti Charge <br /> Activtys ends: am pm Will merchandise be sold? <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 /> District#282bA9 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 a'n'd^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 /> z (signature of responsible arson) <br /> Bill to:' <br /> (name) (address) <br /> --- - --' �``Y`s ------ - ----- -FOR OFFICE USE,ONLY-------------- ---- --------- - ------------ <br /> `5+�. . .- .�R ', ,.•'_� � � -. _ - ' - .:/y "' f; is <br /> �• r <br /> Class " . Iris "Approved by f ,Fr: , .:tert.EG-L Date -.--L <br /> ; <br /> ChargesRental - i - 0 stodial <br /> g <br /> F Z7 y 1^ A <br /> Cooksr r b Other charges <br /> IL <br /> - •/`^ • �./f//'l _; �/� !` ,•�''JYr/!J/��'� <br /> ,r WHITE=ceMMLI lI ceps Y su'l"Onke CoPj' PINK Anbe.ns coos oo�o Mv�Mn r (t iL• ./''} � 1. <br /> 1•• <br />