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Canyawft Serdoss DepaNnMai <br /> 3301 sslhrer Lake Rd s sat AMhom, MN 55418 • Phan:7p 4MM <br /> Facllitles Reservation Form Permit No. -- <br /> Name ' d Home Phone <br /> V <11"A"IL Bus. Phorw -3 '�' L <br /> 4 <br /> Address l^r' L_�..1 I /i�y�/ �%fj �J Date ru <br /> V <br /> Name of Group or Organization ��r L L 1 N� <br /> Intended Use <br /> Date(s) wanted ��li�IF �� '7 Day(s) Su M T W Tl a (circle) ' . <br /> d <br /> Building: : <br /> High School Auditorium <br /> Park View Community Center Cafeteria <br /> Wilshire Park Elem. School Classrooms) N <br /> Other Gymnasium (If High School, circle one: <br /> OLD NEW ) <br /> Kitchen <br /> _Other F41 46 <br /> Doors to open am pm Expected attendance: G' D <br /> Activity begins am '-pm A 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 or 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 1 Ins -- Approved by Date - <br /> Charges: Rental Custodial <br /> Cooks Other charges: <br /> Note: <br /> W""j—Ceenmerq lows 0111100 copy CANARY—fteh . ORIM CO" P —Ca emews Capr OOLD—rVt+illconti C81M <br />