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INDEPENDENT SCHOOL DISTRICT NO. 282 <br /> Community Servicee Department <br /> 3301 Silver Lake Rd • St. Anthony, MN 55418 0 Phone: 781-5021 <br /> Facilities Reservation Form Permit No. <br /> Name / ��^' �'-' � Home Phone Bus. Phone <br /> Addres -3 "��' Date -iF- <br /> Name of Group or anilation <br /> Intended Use. . �� v <br /> Date(s) wanted - -a Day(g) Su T W Th F Sa (circle) <br /> Building: <br /> High School Auditorium <br /> Park View Community Center Cafeteria <br /> Wilshire P?rk Elem.,Scho Classrooms) # <br /> Other T� ? ,� �( d :-o f, Gymnasium (If High School, circle one <br /> OLD NEW ) <br /> Kitchen <br /> Other / 1 <br /> Doors to open am pm Expected attendance: <br /> Activity begins --am _ pm Admission: --Free 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 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 arrarigement. L `� <br /> (signature of responsibl ' rson) <br /> Bill to: <br /> (name) (address), <br /> ---------------------------------------------FOR OFFIC USE ONLY--------------------------�_-_ <br /> Class .45-- Ins Approved by - Date <br /> Charges:.Rental _:22 ��_ Custodial <br /> • Cooks:' Other charges: <br /> Note: <br /> WHITE—CommuMtr 0_4me.o"Ie.�� �, .p.,, .I�0041 IprR,—CwebdIll"COPY GOLD— Apojc4knr.Copy <br />