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7 <br /> INDEPENDENT SCHOOL'DISTRICT NO. 282 .- - <br /> community SeMdes Departinent <br /> 3301 Silver Lake Rd o.St. Anthony, MN 55418 0 Phone:781-5021 <br /> '0. 9C.1,Z <br /> n Permit <br /> Facilities Reservatio Form N <br /> Qme C-k i. Home Phone Bus. Phone <br /> 1 Address Date <br /> Name of Group or Organization <br /> Intended Use <br /> F Sa {circle) <br /> Date(s) wanted r C< I–DhyV(s)11!�u .T Th <br /> Building: it A. <br /> —High School —Auditorium <br /> —Park View Community Center —Cafeteria <br /> —Wilshire Park Elem. School —Classroom(s) # <br /> Other 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 pm Admission: Free Charge <br /> Activity ends —am Will merchandise be sold? <br /> Opecial 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 Bol?do.L 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 r, <br /> fVa ment, rentee agrees to hold harmless <br /> i <br /> il <br /> Ii <br /> it <br /> t rJen <br /> I.S.D. 282 and' i'its representatives from all claims incurred in use of the FR rifte 11 rights and claims for <br /> potential damages incurred in this rental arrangement. <br /> (signaturtof responsible person) <br /> Bill to: <br /> (name) (address) <br /> ---------------- - ----------------------- FOR OFFICE USE ONLY--------- <br /> Class ---. Ins App pp ved by , Date <br /> , <br /> Charges:.Rental Custodial <br /> 7 00, <br /> N <br /> -Cooks 'dtheif'chircl6s: <br /> 7 <br /> L– <br /> Note: <br /> J. <br /> % <br /> 7, <br /> �O 7 <br /> 72' <br /> Co."ty Mn4w 086i C0810diAM CAM CM <br />