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WR <br /> INDEPENDENT SCHOOL DISTRICT.NO. 282 <br /> Community Services Department - <br /> 3301 Silver Lake Rd • St. Anthony. MN 55418 • Phone: 781-5021 <br /> Facilities Reservation Form Permit No. <br /> Name ` M5�5-4's Home Phone Bus. Phone <br /> Address I;3. /l/.9 • fAW— 5 yr Date <br /> Name of Group or Organization Sr-. hrrifO N Y r i ec Deo <br /> Intended Use y0 Fr3A64. Ti2JAeAAqMiqV7_ <br /> Date(s) wanted d(k L y Q q k!jj Days) Su M T W Th F a (circle) <br /> Building: <br /> High School Auditorium <br /> Park View Community Center Cafeteria <br /> Wilshire Park Elem. School Classrooms) q <br /> Other Gymnasium (If High School, circle one: <br /> OLD NEW ) <br /> Kitchen/p_VIRAL 1 — Z-3 <br /> Other �S <br /> Doors to open _am pm Expected attendance: Tee trin <br /> Activity begins F�_am pm Admission: �oase Charge <br /> Activity ends am a.0t 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 /> ff-e_z�-, <br /> (signature of responsi erson) <br /> Bill to: W14-1- 1601 th YEKS <br /> (name) (address) <br /> ---------------------------------------------FOR OFFIC USE ONLY----------------------------------- <br /> Class --I— Ins Approved by Date &h'j <br /> Charges: Rental u - Custodial <br /> Cooks Other charges: <br /> Note: <br /> WHITE—commwtlly ionk"oMlce' %NARY—Swine"OMlee Coq PINK—CustoAlnm Copy OOID—ApptlemVe Coq <br />