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INDEPENDENT .SCHOOL DISTRICT NO. 282 <br /> Community Services Department <br /> 3301 Silver Lake Rd a St. Anthony, MN 55418 • Phone: 781-5021 <br /> Facilities Reservation Form No. <br /> �� 7 Bus. Phone <br /> Name f Home Phone / <br /> Address C'•,.` Today's Date b 7/ <br /> Name of Group or Organization <br /> Intended Use <br /> Date(s) wanted Day(s) Su M T W Th &a (circle) <br /> Building: <br /> High School Auditorium <br /> Community Center Cafeteria <br /> Wilshire Park Elem. School Classroom(s) ft <br /> L_ Other Lr�-�'��r1��T- 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 '06pm Admission: Free Charge <br /> Activity ends am m 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#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 /> ! <br /> J (signature of resp6nsible person) <br /> Bill to: <br /> (name) (address) <br /> ---------------------------------------------FOR OFFICE USE ONLY---------------------------_ ---____-------- <br /> Class Ins Approved by - f _ . _ Date 6 7 <br /> Charges: Rental Custodial <br /> Other charges: <br /> Note: - <br /> WHME—cmnnwrrh Serve..OMIa copy CANARY—Isudmee Ofte copy PINK—Cu.lodam Copy GOLD—Applkanre Copy <br />