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INDEPENDENT SCHOOL DISTRICT NO. 282 r - <br /> Community Services Department <br /> 3301 Silver Lake Rd • St. Anthony, MN 55418 • Phone: 781-5021 <br /> Facilities Reservation Form Permit No. <br /> Name4-ov 6 <br /> 11W- 1. .� � Home Phone Bus. Phone <br /> Address1 Today's Date <br /> Name of Group or O ganization <br /> Intended Use <br /> Dates) wanted _ Day(s),Su;M T W Th F Sa (circle) <br /> Building: <br /> High School Auditorium <br /> Community Center Cafeteria <br /> Wilshire Pars Elem. School Classrooms) # <br /> Other Gymnasium (If High School, circle one: <br /> LARGE SMALL ) <br /> Kitchen <br /> Other <br /> Doors to open am pm Expected attendance: <br /> Activitybegins -am m Admission: Free Charge <br /> Activity ends am X-F&lpm Will merchandise be sold? <br /> Special arrangements needed (chairs, cooks, AV equipment. etc.): <br /> -r �•�rJ� -7-.�-��L."c� ll_."R.�L'_•-�'£^'l i....j.'_Lf`� � � t • I• l /` I J f .�� 1 ��..1 4 <br /> J� <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,l 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 perspn) <br /> Bill to: <br /> (name) (address) <br />-----_----------------------------------FOR OFFICE USE ONLY------------------------- --- --- -- <br /> Class Ins Approved by //4. Date f" �� •_� <br /> 1, <br /> Charges: Rental _ Custodial <br /> Cooks Other charges: <br /> Note: <br /> i <br /> wHITe—col--4y s.rnc"olnce copy cnw►nr—su.ir..s Omo.cam„ OINK_am%&dh�C�. GOLD_Anepea ra r <br />