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INDEPENDENT SCHOOL DISTRICT NO. 282 I <br /> Community Services Department <br /> 3301 Silver Lake Rd • St. Anthony, MN 55418 • Phone: 781-5021 2 <br /> Facilitation Form Permit No.'-�/ V <br /> Name !/e u � L5,5,17i;Tme Phone 631- 3Bus. Phone •ly <br /> Address 3-ft,/�l w4/-ds Today's Date 7-mod -yG <br /> Name of Group or Organization 1441"/AU <br /> Intended Use <br /> Date(s) wanted - ay(s) Su M T W Th F Sa (circle) <br /> Building: / <br /> High School Auditorium <br /> Community Center Cafeteria <br /> Wilshire Park Elem. School Classroom(s) # <br /> Other -L..) Gymnasium (If High School, circle one: <br /> LARGE SMALL ) <br /> Kitchen <br /> Other <br /> Doors to open am pm Expected attendance: <br /> Activity begins am ���pm Admission: Free Charge <br /> Activity ends am 1'00pm 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 forgiving <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 /> (signature of responsi person) <br /> Bill to: <br /> (name) (address) <br />---------------------------------------------FOR O FICE U1SE ONLY------------------------------------------------- <br /> Class Ins Approved by �✓ r Date ` <br /> Charges: Rental Custodial <br /> Cooks Other charges: <br /> Note: <br /> WHITE—Community Services Office Copy CANARY—Business Office Copy PINK—Custodians Copy GOLD—Applicant's Copy { , <br />