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• INDtPENDENT SCHOOL DISTRICT NO. 262 <br /> Community Services Department <br /> 3301 Silver Lake Rd • St. Anthony, MN 55418 • Phone: 781-5021 <br /> 1 ' Facilities Reservation Form Permit No. <br /> Name �� QaRorr Home Phone �T i � f i`{ Bus. Phone -%�='" <br /> Address 7_3 11L ? Date _11 e <br /> Name of Group or Organization <br /> 4 <br /> Intended Use _ .-fl f •\ ~a.. +C .,•/ .1 ,,� ��� ���,��C <br /> Date(s) wanted ,j 4r - t'\J-+;;C� Day(s) Su M T W Th Fr Sa (circle) <br /> Building: <br /> High School Auditorium <br /> Park View Community Center Cafeteria <br /> Wilshire Park-Elerrr. School ! -' Classroom(s) # <br /> Other Gymnasium (if High School, circle one: <br /> OLD NEW ) <br /> Kitchen <br /> S.0ther _T?:;,.Vt 1 r!9W Cxr r -C rte. c <br /> Doors to open --- am pm Expected attendance: �� + <br /> Activity begins am pm Admission: Free Charge <br /> ►, 1 <br /> Activity ends am pm Will merchandise be sold? <br /> Special arrangements needed (chairs, cooks, AV equipment, etc.): 1 �• �= ��_ r • <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 /> (signature of responsible parson) <br /> Bill to: <br /> (name) (address) <br /> ----------------------------------------------FOR OFFICE USE ONLY-----------------------------------------------. <br /> / / �f., C <br /> Class Ins Approved by 7 <br /> 1 • Date ;' <br /> Charges: Rental Custodial ' <br /> Cooks Other charges: • <br /> Note: - <br /> _ t• X.Y// <br /> "� ± �r �•Ll-WHITE-CaronuNty Simi.OMe.Copy I CANAIIf—Sudn.s.OMe.Copy'PIIlKCwwa� �`•( t� <br /> copy ooLo—Appne.nr.ceps <br />