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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. 7.• '~ <br /> c�1 <br /> Name Home Phone 2 Bus. Phone <br /> Address r' '��+ Today's Date <br /> Name of Group or Organization L- <br /> intended Use <br /> Date(s) wanted Day(s) Suits T W Th F 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 /> LARGE SMALL ) <br /> Kitchen <br /> Other <br /> Doors to open am ' pm Expected attendance: <br /> Activity begins am pm Admission: Free Charge <br /> Activity nds <br /> y am pm Will merchandise be sold. • <br /> Special arrangements needed (chairs, cooks. AV equipment, etc.): <br /> 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 forgiving <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 /> --------------------------------------------- <br /> FOR OFFICE USE ONLY------------------------------------------------- <br /> Class Ins Approved by Date <br /> Charges: Rental Custodial • <br /> Cooks Other charges: <br /> Note: <br /> t <br /> � WYITQ—/•--�.._Iw!-w.l_-.Arts-�w__.. w.u.nv n.__.____w.n_-w.._. w..... w.._•_w_-_ <br />