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�L-NJLAT �P` H�AX Vo" , f—A, <br /> C <br /> 3MI 90m Lake,Rd St. An", UN MIS 9 Pftone.:7SIi-.5M,.1 <br /> Faclildew.Rwwrvagon Form_--- 'Permit No. <br /> -Name-1 *J C& HomePhone 2 el-211 1.-Bus.. Phone 931-,252 <br /> Address ''Li , ILA Date <br /> Name of,Group,or Organization,_L, A L r. r 15 13 <br /> Intended Use L <br /> Date(s).wanted 1 41-74-0 N Day(s) Su M T Wt Th F 0(circiiiii" <br /> :Building: <br /> —High School —Auditorium <br /> —Park View Community Center —Cafeteria <br /> —Wilshire Park Elem. School —Classroom(s) 0 <br /> —Other Gymnasium (it High School, circle one: <br /> OLD NEW <br /> —Kitchen <br /> ,e Other <br /> Doors toopen —am _pm Expected attendance: 2,0 <br /> Activity begins am prn Admission: —Free Charge <br /> Vctivity ends —am _2 ' ?C'prn <br /> Will.merchandise be sold? <br /> Special arrangements needed (chairs, cooks. AV equipment; e'tc.): <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 0282. As a group-or organizational agenti I will attend this-function. and I will be solely responsible for glilng <br /> anjand all instructions to the custodiansor other support personnel."Pre'sentation 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. 2,82 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 /> ad <br /> (signature of responsible Wson) <br /> Bill to: <br /> iname) (address) <br />------ —---------------------------FOR OFFICE USE ONLY-----------,-------- - <br /> Class Ins <br /> Approypd;by Date <br /> Charges:.Rental Custodial <br /> Cooke- <br /> Other chargw, <br /> Note: <br /> COMMMMO-80 vicell 019"Cc" - CAMPY—Oushwo OW&o C4wV PIM—Caeft6wo Copy GOLD—Appftwre Copy <br />