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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 /> 1. Z/71_; <br /> Facilities Reservation Form Permit No. <br /> Name ���? f Home Phone 3U7 Bus. Phone <br /> (122-c - \ <br /> Address J <br /> (!;l '7 ( 1,�� L Today•s Date <br /> Name of Group or Ofganization <br /> Intended Use USa <br /> Date(s) wanted <br /> �)l u.t � ) Z�S� Day(s) Su M T W Th ci rcle) <br /> Building: <br /> High School Auditorium <br /> Community Center <br /> Cafeteria <br /> Wilshire Park Elem. School -Classroom(s) <br /> . - <br /> -_ - - . _.: Gymnasium (If High circle rc a one: <br /> - . . Other`• .- .. _ _. <br /> �Y ��� t ��} � LARGE SMALL ) <br /> • '1� t d I Kitchen <br /> Other ..._ _• • .. -: __. - -- - -- " <br /> Doors to open am pm - Expected attendance: - -- <br /> •- Activity begins am pm Admission: Free Charge <br /> 3O Will merchandise be sold?; <br /> Activity ends - - - am pm _ _ . " - <br /> Special arrangements needed (chairs, cooks, A�egOipment, eta) - <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,l will attend this function,and I will be solely responsible for giving <br /> any and all instructions to the custodians or other support personnel.Pr tation of this permit to the custodian on <br /> duty is necessary for admittance for the initial date. In accepting this rra geme tee agrees to hold harmless <br /> I.S.D. 282 and its representatives from all claims incurred in use of th facili .R tee aives all rights and claims for <br /> potential damages incurred in this rental arrangement. <br /> (signal re of responsible person) <br /> Bill to: <br /> .(address) <br /> (name) <br /> .---------------------------------------FOR OFFICE USE ONLY------------------------------------------------- <br /> Class Ins Approved by , �� ',CrC1i� � l/l -/r¢� Date <br /> Charges: Rental= Custodial <br /> Cooks ' Other charges: <br /> '-Note: (� .F �• �l - -G`"�it'7"�--" �_-rt..a-J - .� � <br /> Ilk <br /> l Q, - <br /> WHITE—CanmuNly S.nket Office Copy CANjkRY—9ude*ss Ofrk*Copy PINK—CudoOlam Copy GOLD—Applicant's copy <br />