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INDEPENDENT SCHOOL DISTRICT NO. 282 <br /> Community Services Department <br /> 3301 Silver Lake Rd • St. Anthony, MN 55418 a Phone: 781-5021 <br /> .Facilities Reservation Form Permit No. ' <br /> Name Y — — Home Phones"-1'sc�Y Bus. Phone `� �- ZC <br /> Address �(�� 1 3 Z7 tti ,� c /V'L — Date 3 hc�)yy <br /> Name of Group or Organization <br /> Intended Use ^ .�<< �C �-..! �t �.r• �►,�ti� - <br /> -7 . <br /> Date(s) wanted A w'��% <1 Day(s) Su M T W Th F 40 (circle) <br /> Building: <br /> High School Auditorium <br /> Park View Community Center Cafeteria <br /> Wilshire Park Elem. Spool Classroom(s) # <br /> XOther Gymnasium (if High School, circle one: <br /> OLD NEW ) <br /> Kitchen it <br /> �SOther ��-� <br /> Doors to open am pm Expected attendance: 41, <br /> Activity begins -7--c L-am pm Admission: Free Charge <br /> Activity ends am % C pm Will;merchandise be sold? <br /> Special arrangements needed (chairs, cooks. AV equipment, etc.): ��� <br /> • <br /> Ftji,' hZc' �- C f <br /> i <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 1 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. n <br /> (si ature of responsible person) <br /> � Bill t0: -1 <br /> (name) (address) <br /> ---------------------------------------------FOR OFFICE USE ONLY------ ------------- <br /> Class Ins Approved by Date <br /> Charges: Rental �� �•�� ���L d� �-�' Custodial <br /> Cooks Other charges: <br /> Note: <br /> WMT1—c _jr s...a«onk@ cap, cawMr—WJWAa o1aet CM pjM—CuMdU .Co" Qot.o—Appkw '.Ca" <br />