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.INDEPENDENT.SCHOOL DISTRICT NO. 282. <br /> r' Community Services Department <br /> 3301 Silver Lake Rd • St..Anthony, MN 55418 0 Phone: 781-5021 <br /> Facilities Reservation Form Permit No. • <br /> Name 1LI- Home Phone Bus. Phone <br /> Address 1f. ` / / I ✓ 1L!f.� <br /> Today's Date <br /> 1 <br /> Name of Group or Organization . <br /> Intended Use <br /> Date(s) wanted y1 Day( Su M T W Th F Sa (circle) <br /> i <br /> Building: <br /> High School Auditorium <br /> Community Center Cafeteria <br /> Wilshire Park Elem. School Classroom(s) # <br /> Y Other Gymnasium (If High School, circle one: <br /> rtT LARGE SMALL ) <br /> Kitchen <br /> Other <br /> Doors to open am C"pm Expected attendance: %' y <br /> Activity begins am pm Admission: Free Charge <br /> Activity ends am '�-G 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 /> 74 4e <br /> (signature of responsible person) <br /> Bill to: <br /> (name) (address) <br />----------------------------------------------FOR-OFFICE USE ONLY------------------------------------------------- <br /> Class Ins Approved by Date <br /> Charges: Rental Custodial • <br /> Cooks Other charges: <br /> Note: <br /> ­7 <br /> WHITE—Community 8orrkati Office Copy CANARY—Business OHIU Copy PINK—Custodians Copy GOLD—Appllwnra copy <br />