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INDEPENDENT SCHOOL DISTRICT NO. 282 ` 6 J. <br /> Community Services Department <br /> 3301 Silver Lake Rd 0 St. Anthony, MN 55418 • Phone: 781-5021 <br /> Facilities Reservation Form Permit No. •� <br /> Name- �' +���I I>C ei L Home Phone Bus. Phone % Al <br /> Address 662 A,� 1 c? i �.�r Today's Date <br /> Name of Group or Organization /�r�► T/�r,T:�f f-ii,� / ��% <br /> Intended Use <br /> Date(s) wanted �'� ��? `f :f <br /> Day(s) Su M T W Th PtiS (circle) <br /> Buildirig: <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 /> ) _ <br /> :..�_ �:. .•?x:21 ;; Other <br /> Doors to open am pm Expected attendance: �' 3 <br /> Activity begins ' ' am pm Admission: Free Charge <br /> Activity nds m <br /> Y a pm Will merchandise be sold. <br /> Special arrangements needed (chairs, cooks, AV equipment, etc.): <br /> A , <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 /> ,I I <br /> Class Ins Approved by j. _ Date `?/ J i C,1 ' <br /> Charges: Rental Custodial <br /> Cooks Other charges: <br /> Note: <br /> WHITE—Community Services Ottloa Copy CANARY—Business Office Copy PINK—Custodians Copy GOLD—Applicant's Copy <br /> i <br />