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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 Reservauo!)ro �3/ Permit No. <br /> U Name LriOkJ°4/�D ASy4 Home Ph9ple - 42 O/ Bus. Phone <br /> 3v,0 z9 r1l <br /> Address Ajl'/ Date <br /> Name of Group or Organization <br /> Intended Use /��/��f�b� //1600 . &&'All C <br /> Date(s) wanted �r/ Day(s) Su M T W Th F a (circle) <br /> Building: <br /> High School Auditorium <br /> Park View Community Center Cafeteria <br />= Wilshire ark Elem. School Classroom(s) # <br /> Other -lLk Ls/ .42ZA/4! 10*-e< Gymnasium (If High School, circle one: <br /> OLD NEW ) <br /> Kitchen <br /> Other <br /> Doors to open am CO pm Expected attendance: 1112 <br /> Activity begins4c_am I•DO pm Admission: Free Charge <br /> Activity ends am ILVQ pm Will merchandise be sold? <br /> Special arrangements needed (chairs, cooks. AV equipment, etc.): j&-'7e- ';6,41s 110 <br /> �G/'SOh,, Si�i irk' �f FiJC Y�i�iP; U.5 e- O <br /> 5kg day/ nBK / <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 tpeafacility. a tee w ves all ' hts and claims for <br /> potential damages incurred in this rental arrangement. <br /> (s gnature of responsible person) <br /> Bill to: <br /> (name). (address) <br />----------------=------------------------------FOR OFFICE USE ONLY---------=--------------- -------- <br /> Class Ins Approved by Date <br /> Charges:- Rental Custodial <br /> Cooks Other charges: • <br /> Note: <br />