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J <br /> :INDEPENDENT SC.HOO:L�:DISTRICTWO..282 <br /> Community Servlcoe'Oepartrnent <br /> ..3301.Silver Lake Rd • St. Anthony,MN.:554.18,•: Phone: 781-5021 <br /> Facilities Reservation Form p Permit No. <br /> Name Home Phone J - 313us. Phone <br /> Addre -�O Date <br /> Name of Group or Organization <br /> Intended Use _ <br /> Date(s) wanted d Day(s) Su M T W Th Sa <br /> © (circle) <br /> Building: <br /> High School Auditorium <br /> Park View Community Center Cafeteria <br /> Wilshirarkem hop <br /> ether �I�r ar� U�/��� Classrooms) q <br /> Gymnasium (If High School, circle one: <br /> O ) <br /> Kitchen OLD NEW <br /> Other <br /> Doors to open _ am pm Expected attendance: <br /> Activity begins am ,�L pre Admission --Free <br /> Charge <br /> Activity ends am c )pm Will merchandise be sold? /07 <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 arrangement. <br /> (signature of responsible person) <br /> Bill to: <br /> (name) <br /> (address) <br /> ------------------------------------------FOR OFFICE USE ONLY-----------------------------—_� <br /> // � <br /> Classf Ins Approved by Date <br /> Charges: Rental —% Custodial <br /> • <br /> Cooks Other charges: <br /> Note: <br /> WHITS—Cmam;elty ah.olnes copy CANARY—awlmu olnoe Copy PINK—CupoUero Copy GOLD—Mpie+,rr•poor <br />