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INDEPENDENT SCHOO_ DISTRICT NO. 282 7. :: Community Serylces Department 3301 Silver Lake Rd • St. Anthony INN 55418 • Phone: 781-5021 • Facilities Reservation Form Permit No. Name. �� C ,•� Home Phorie ` ;o Bus. Phone = w b cr Address �;'. : �� C�� r 1 r Of-' Date �� '• Name of Group or`,Organization "' 1± '1 Intended Use Day(s) Su M T W Th F (circle) Date(s) wanted T 9� Building: High School Auditorium Park View Community Center Cafeteria Wilshire Park Elem. School Classrooms) # Other ;�,1 ` , Gymnasium (If High School, circle one: r'a't v OLD NEW ) Kitchen M C 0 j=1 L.17_ Other Doors to open am pm Expected attendance: Activity begins am pm Admission: Free Charge �� - • Activity ends am pm Will merchandise be sold. Special arrangements needed (chairs, cooks. AV equipment, etc.): ji J -A <j GA'11C 6G ALCLNuL tDCQrn I T I hereby certify that I am an agent of the above named group or organization and am authorized to accept in their name the responsibility for observance of the rules and regulations of the Board of Education, Independent School District#282. As a group or organizational agent,I will attend this function,and I will be solely responsible for giving any and all instructions to the custodians or other support personnel.Presentation of this permit to the custodian on duty is necessary for admittance for the.initial date. In accepting this arrangement, rentee agrees to hold harmless I.S.D. 282 and its representatives from all claims incurred in use of the facility.Rentee waives all rights and claims for potential damages incurred in this rental arrangement. (signature of responsible person) Bill to: (name) (address) FOR OFFICE USE ONLY----------------------- ___ Class _ Ins Approved by TR - Date as Charges: Rental Custodlal COOks� -- �, Other char es�-n-j �Y `- '7" 1W ,17 �—r^a�s.es•� � `. w.. Y+ i. '^," r M » Tin `tom•":..