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INDEPENDENT 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 z r,�.—�r;,�,U r f°'�'. Home Phone Bus. Phone k" 't <br /> Address Date FTJ r I <br /> Name of Group or Organization <br /> . f- <br /> Intended Use I <br /> Date(s) wanted LJ Day(s) Su M T W(` ,,F.Sa (circle) <br /> Building: <br /> High School Auditorium <br /> Park View Community Center Cafeteria <br /> Wilshire P rk Elem. School Classroom(s) <br /> - Other �? .� ?'`-i=r.•/ ;�i,, ��,� - - _ Gymnaium (If High3 ch' iol;'dficfe one d` <br /> OLD NEW ) <br /> �d•v:'/� Kitchen <br /> Other <br /> Doors to open.'—am, pm ' Expected attendance: <br /> Activity begins he " am pm Admission: re 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 1 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. f %. J >= <br /> f'` (signature of responsible person) <br /> � r <br /> Bill to: ( 'r 1 <br /> (name) (address) <br /> FOR OFFICE USE ONLY---------------------------------r--------------- <br /> Class Ins Approved by Date <br /> Charges: Rental Custodial <br /> Cooks Other charges: • <br /> Note: iz; I <br /> onk ,l!c Y—Su C <br /> p,PNK—CuAaw CaOr OOLD—AOnri COPY OT Cemmutot s <br />