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r� INDEPENDENT SCHOOL DISTRICT NO. 282 Community Services Department 3301 Silver Lake Rd a SL Anthony, MN 55418 • Phone: 781-5021 �// Facilities Reservation Form Permit No.�-4 • Name C! �a –� �0.:%`2,j d ^' Home Phone 3SI Bus. Phone e7L 2 / Address .3 °Z3 ' w�5 ✓i s1— Date Name of Group or Organization ��'� �'� �` GiIJ ` C_ Intended Use �� GNP PDV� 'E'B�A'L ✓��ly�� " Date(s) wanted — OF ��^� Day(s Su M T W Th F Sa (circle) Building: High School Auditorium Park View Community Center Cafeteria Wilshire Pprk Elem. School Classrooms) # Other p1910r–K Gymnasium (If High School, circle one: OLD NEW ) Kitchen Other Doors to open am pm Expected attendance: Activity begins/2:1-)am -3A pm Admission: Free Charge Activity ends am 6149 pm Will merchandise be sold? d �� • Special arrangements needed (chairs, cooks, AV equipment, etc.): I hereby certify that I am an agent of the above named group or organization and am authorized to accept in their name the responsibility for observance of the rules and regulations of the Board of Education, Independent School District#282. As a group or organizational agent,I will attend this function,and 1 will be solely responsible for giving any and all instructions to the custodians or other support personnel.Presentation of this permit to the custodian on duty is necessary for admittance for the Initial date. In accepting this arrangement, rentee agrees to hold harmless I.S.D. 282 and its representatives from all claims incurred in use of the facility. Rentee waives all rights and claims for potential damages incurred in this rental arrangement. / (signatur of responsible person) Bill to: name (address) FOR OFFICE USE ONLY Class Ins Approved by Date �✓ Charges: Rental _� / Custodial • Cooks Other charges: Note: WHrn—CaMMWdly"nftM M"copy CANMY—swine"OMIu copy PINK—CwbAlau Copy OOID—Appllnnrs COPY