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YNILJEPIGNUEN SCHUCIL 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 Phone - '5507-57 Bus. Phone-k.-' <br /> Address',34 G' f - '' >' Date <br /> ._ <br /> Name of Group or Organization <br /> Intended Use <br /> Date(s) wanted < `f r Day(s) Su M .T W Th FI .. (circle) <br /> Building: <br /> High School Auditorium <br /> Park View Community Center Cafeteria <br /> Wilshirepark le S o I _ Classroom(s) # <br /> Other '2 g' Gymnasium (If High School, circle one: <br /> OLD NEW ) <br /> Kitchen <br /> Other <br /> Doors to open am pm Expected.attendance: <br /> Activity begins 00 am pm Admission: Free Charge <br /> Activity ends am prn 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 Date <br /> Charges: Rental /21 Custodial <br /> Cooks Other charges: <br /> Note: <br /> WHITE—Community Services Office Copy CANARY—Business Office Copy PINK—Custodians Copy GOLD—Applicant's Copy <br />