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INDEPENDENT'SCHOOL DISTRICT NO.- 282 <br /> Community Services Department <br /> 3301 Silver Lake Rd 0 SL'Anthony, MN 55416 0 Phone:781-5021 <br /> 9C11 3 <br /> Facilities Reservation'. Form . Permit No- <br /> me Bus. Phone <br /> Home Phone. <br /> Address Date <br /> Name of Group or Organization <br /> Intended Use <br /> Day(s) !�u% ;VI@Th F Sa {circle) <br /> Date(s) wanted Lip IzZi <br /> 3 <br /> Building: <br /> —High School —Auditorium <br /> —Park View Community Center Cafeteria <br /> -Wilshire Park Elem. School —Classroom(s) # <br /> Other Gymnasium (it 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 C, 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 Boardof 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;arr, m t, rentee agrees to hold harmless <br /> 'i ?eIeentee>jjves all rights I.S.D. 282 and its representatives from all claims incurred in use of the f i MIR h and claims for <br /> potential damages incurred in this rental arrangement. <br /> (signature"'of responsible person) <br /> Bill to: <br /> (name) (address) <br /> ----------------- OFFICE USE ONLY--------------------- - <br /> C S_ <br /> la s Ins . App ved by bat"e' <br /> ".,. ,Charges:'.Rental.­ Custodial - <br /> Other charges: <br /> ' <br /> oo k s <br /> 00e;-77 <br /> Note: <br /> if- <br /> 7 <br /> cusbawo co" a" <br /> 7! <br />