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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. <br /> Name ���` �✓ -� Home Phone. 77 Bus. Phone <br /> Addres _KO 2/ if - I _ Today's <br /> Name of.Group or Organization <br /> Intended Use <br /> Date(s) wanted s=ue t: / % Day(s) Su M T W J 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 ends am pm 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 /> (signature of responsible person) <br /> Bill to: <br /> (name) (address) <br />---------------------------------------------FOR OFFICE USE ONLY------------------------------------------------- <br /> Class Ins Approved by.- <br /> �'-� �'�J ��• (f '../1 �`�. <br /> ' Date <br /> PP <br /> Charges: Rental Custodial <br /> Cooks Other charges: • <br /> Note: � ✓�y f�. � i/ !(_-C_'-: - =j`"?�-:!f_-`-'�- ::r 'f"i li i c r /� �' <br /> WHITE—Community Services Ottlee Copy CANARY—Business Office Copy PINK—Cuetodlens Copy GOLD—Appltcenre Copy <br />