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INDEPENDENT SCHOOL DISTRICT NO, 282 <br /> Community Services Department � <br /> 3301 Silver Lake Rd m 0t. Anthony, MN 55418 * Pbmmw: 781-5021 <br /> Facilities Reservation Form Permit No.d±__' <br /> Name <br /> Home Phone <br /> Bus. Phone ' <br /> _�. <br /> Name of Group or Organization <br /> Date(s) wanted <br /> Buiiding: <br /> —High School —Auditorium <br /> _-_-'Park View Community Center —Cafeteria <br /> —Wilshire.Pqrk Elem. 3 _-_-C|ossroorn(s) # <br /> Other —Gymnasium (\t High Schoo|, circle one: <br /> OLD NEW <br /> —Kitchen <br /> ----- � <br /> Doors 0oopen -_-_---am -------'pmn Expected attendance: <br /> Activity begins j, Q um pm Admission: <br /> Activity ends ------_'om ----__-pnn Will merchandise be sold? <br /> Special arrangements needed (chairs, cooks, AV equipment, etu ): <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. Asa group mr organizational agent, I will attend this function,and Iwill 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 ioidw| date. In accepting this r ongomont ren\ e agrees toho|d harmless <br /> I.S.D. 282 and its representatives from all claims incurred in of the facility. <br /> potential damages incurred in this rental arrangement. � <br /> � <br /> -- (sigpalu,em responsible person) � <br /> Bill to: � <br /> tnarw) (address) � <br /> ------------------------------FOR OFFICE USE ONLY'--------------------- <br /> C|oou -_---_ |ns _----_ Approved by Date ~- <br /> Charges: Rental Custodial <br /> Cooks Other charges: <br /> Note: <br /> ' <br />