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INDEPENDENT SCHOOL DISTRICT NO. 282 <br /> Community Services Department ' <br /> 3301 Silver Lake Rd Y St. Anthony, MN 55418 • Phone: 781-5021 <br /> Facilities Reservation Form Permit No. 1— <br /> game Home Phone 7fc)"93/8 Bus. Phone <br /> Address z�7D `r Date <br /> Name of Group or Organization �`oF?�� r /Uc��Zi�l• <br /> Intended Use <br /> Date(s) wanted -s S 8 Day(s Su M T W Th Sam (circle) <br /> Building: <br /> High School Auditorium <br /> Park View Community Center Cafeteria <br /> Wilshire Park Elem. School _ Classroom(s) # <br /> Other !BALL �'iELoS �2��'� / `� Gymnasium (If High School, circle one: <br /> OLD NEW ) <br /> � Kitchen <br /> Other <br /> Doors to open am pm Expected attendance: <br /> Activity begins am �e'� 1 <br /> _� pm Admission: Free �� ���'1✓harge <br /> Activity ends am pm Will merchandise be sold?, <br /> *pecial 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,l 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 /> 9 <br /> (signature of responsible person) <br /> Bill to: <br /> (name) (address) <br /> --------------------------------------------FOR OFFICE USE ONLY------------------------------------------------- <br /> Class Ins Approved by Date o <br /> Charges: Rental Custodial <br /> • Cooks Other charges: <br /> Note: <br /> ..•....e. rte...-..-,...�...r r•a..Cor•. r.AwAov Cu.tao's-s CC— r,OID- �opltean•.fow <br />