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INDEPENDENT SCHOOL DISTRICT NO. 282 6,Cos <br /> Community Servims Department <br /> 3301 Silver Lake Rd • St. Anthony. MN 55418 • Phone: 781-5021 <br /> Facilities Reservation Form Permit No. <br /> Name j 1 Home Phone- L�Bus. Phone �'yG`-(�` <br /> Address �-l�[���• �i L �[,�day's Date <br /> Name of Group or Organization 1 ! �' �� � f1U <br /> w <br /> Intended Used-�-2? <br /> Date(s) wanted. Day(s) Su M T W Th Sa (circle) <br /> Building: <br /> High School Auditorium <br /> Community Center Cafeteria <br /> Wilshire Park Elem. School Classroom(s) # <br /> Other: --�� Gymnasium (If High School, circle one: <br /> C.U•(�C-�. !-f LARGE SMALL ) <br /> Kitchen _. <br /> Other .r. . <br /> Doors to open am pm Expected attendance: <br /> Activity begins am m Admission: Free Charge <br /> Activity_.ends- am- 7 m Will merchandise be sold? <br /> Special arrangements-needed,(t: fairs, cooks. AV equipment, etc.): , <br /> I herebycertify_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,l 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.4' resentatives 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 fo: -Y - <br /> -- - - - _(name). _ (address) . . . <br />------- —==="=—=— -----=— -----FOR O FICE USE ONLY------ --------------------- --------- <br /> Class Ins Approved b <br /> Chargest Rental Custodial <br /> r <br /> tip ,-�`Cooks�{ - Other charges: <br /> r Notew-4"Vf2 : ; ` ;,a [ri-%` ': :< r <br /> 'il s� IMMITQ CanrMrdly»wrvleita 01 . <br /> CP r CA14rM'� Y•.•,.�ftr i:i w O^c M Ia W , PINCuw 00L0 APpl krn h Q*V S <br /> _ <br /> ClY°�,�¢'''`' � �� G i il4 ✓' ,�,. ,r.�L^✓_ ��.•1`3.. I'� ,� tl xc .. <br /> .:�,< .., z. - _. - _. . ......La..?.:a'....t• .".�1 tea>. _..__.. _ -_.....�' _ ____ . . 7-.,... ..... ._. <br />