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INDEPENDENT SCHOOL SCHOOL DISTRICT NO. 282 <br /> Community Services Department <br /> 3301 Silver Lake Rd • St. Anthony, MN 55418 • Phone: 781-5021 <br /> Facilities Reservation Form Permit No. <br /> Name f S �' ��4.d Home Phone Bus. Phone >;1 r/( <br /> Address „� `�Z )&Z I / ►�u'�. Date _ - S' 90 <br /> Name of Group or Organization <br /> Intended Use <br /> Date(s) wanted - - a % .` 24 o Days) AA T W Th PSa., (circle) <br /> Building: <br /> High School Auditorium <br /> Park View Community Center Cafeteria <br /> Wilshire Park Elem. School Classrooms) # <br /> ___%�Other Gymnasium (If High School, circle one: <br /> L trl,'C.e OLD NEW ) <br /> •_ Kitchen <br /> Other <br /> 7'. <br /> Doors to open am pm Expected attendance: <br /> J <br /> Activity begins am pm Admission: Free Charge <br /> Activity ends am pm Will merchandise be sold? • <br /> Special 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,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 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 /> (sign ure Pf res,56nsible person) <br /> Bill to: <br /> (name) (address) <br /> ----------------=------------------------------FOR OFFICE USE ONLY------------------------- -- -------- <br /> Class Ins Approved by Date J <br /> r <br /> C arg a to ,.� <br /> - gal f <br /> NEAR. � j`z.1j k'v+. <br /> %AMW Oth �g r +�py"F a• at. <br /> -. <br /> yy '3 i. pa t -Sj'- S � t j.. �' • <br /> Q <br /> Gf J��� � S .o-�-,t i p•v �i-,xr... t�4�•.. ,- p113u• .jai. ;q`� .„;1 <br /> -�. --.. 1 R).'�.. �ir�w• :.. _ . ��h�l��N��M�+G���I±...� YOWL v.���../VLY�, VYI��J-k��}?x}f ">'�Y'4 <br />