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INDEPENDENT SCHOOL DISTRICT NO. 282 <br /> Community Services Department <br /> 3301 Silver Lake Rd • St. Anthony, MN 55418 a Phone: 781-5021 <br /> _ Facilities Reservation Form Permit No. <br /> Name Home Phon Bu . Phone f • <br /> Address''S-�S'� r - To ay's Date <br /> Name of Group or Organization <br /> Intended Use <br /> Date(s) wanted %! Day(s) Su M T W Th F Sa (circle) <br /> f <br /> Building: <br /> High School Auditorium <br /> Community Center Cafeteria <br /> Wilshire Park Elem. School _ Classroom(s) # <br /> Other f �.% Gymnasium (If High School, circle one: <br /> —' LARGE SMALL ) <br /> ( ' Kitchen <br /> Other <br /> Doors to open am pm Expected attendance: <br /> r'r , -r') <br /> Activity begins am :1=1_`�`1-pm Admission: Free Charge <br /> Activity ends am '1° pm Will merchandise be sold? <br /> Special arrangements needed (chairs, cooks, AV equipment, etc.): <br /> �llei per <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 /> (signature of responsible person) <br /> Bill to: <br /> (name) (address) <br /> -FOR OFFICE USE ONLY ; <br /> Class Ins Approved by �' '� '� 'i `' �-- <br /> •�• Date � <br /> r <br /> Charges: Rental Custodial <br /> Cooks Other charges: • <br /> Note: ��f •, 1.--}l "�-1.�� .: �.,.:. _. <br /> WHITE—Community services Office Copy CANARY—Business O"Ice Copy PINK—Custodians Copy GOLD—Appikenra Copy <br />