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//0 <br /> INDEPENDENT SCHOOL DISTRICT NO. 282 A9,03-a,117, ) <br /> Community Services Department <br /> 3301 Silver Lake Rd * St. Anthony, MN 55418 • Phone: 781-5021 Q <br /> Aft Facilities Reservation Form Permit No. � / <br /> Name _�JCL► -& Home Phone - !aus. Phone/739S- 166 l <br /> Address , Dale /99 <br /> Name of Group or Organization ad4n2::� <br /> Intended Use NQ- A W­e <br /> i <br /> Date(s) wanted �_ Day(s) Su M T WI F Sa (circle) <br /> Budding: <br /> High School Auditorium <br /> Park View Community Center Cafeteria <br /> Wilshire Park ElerA. $c of Classrooms) a <br /> Other CAIXX fd_•E x c. Gymnasium (If High School, circle one: <br /> OLD NEW ) <br /> Kitchen <br /> Other r� <br /> Doors to open am pm Expected attendance: <br /> Activity begins '15- am /0 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 x282. 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 /> (signalwe of responsible person) <br /> Bill to: <br /> (name) (address) <br />--------------------------------------------FOR Off ICE_ USE O LY----------------------------------------------- <br /> Class Ins Approved by Date - _ <br /> Charges: Rental Custodial <br /> JCooks Other charges: lei <br /> f <br /> WHITE—Communlly services Office Copy CANARY—Business Office Copy PINK—Cuslodlans Copy GOLD—Appllunh Copy <br />