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r.�',��'� -c� ' '� ^�`-�p"' , , �-` ` r. .­X <br /> . . . ' <br /> ' <br /> INDEPENDENT SCHOOL DISTRICT NO, 282 <br /> community Services Department <br /> 3301 Silver Lake Rd III, St. Anthony, MN 55418 * Phone: 781-5021 <br /> ' <br /> Facilities Reservation Form Permit No. <br /> Home Phone Bus. Phone._.� <br /> Address3e/_ Date <br /> Name of Group or Organization <br /> Intended Use <br /> F 'Sa (circle) <br /> � <br /> _----High School -Auditorium <br /> Park View Community Center ____Cafeteria <br /> Wilshire Park Bem. Schoo| -Classroom(s) � <br /> __---O\hpr ____Gymnasium (If High School, circle one: <br /> OLD NEW ) <br /> -_-__Kitchen <br /> -Other <br /> Oouro1uopen _-_----am pnn/ Expected attendance.- <br /> -� <br /> Activity begins __--__am ----_--pnn Admission: -Free Charge <br /> ' <br /> �(� -` <br /> Activity ends _--_-_am -_---_-pn� VV/(| merchandise be sold? <br /> Special arrangements needed (chairs, cooks, AV equipment, otcj: -- <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 tq the custodian nn <br /> duty is necessary for admittance for the initial date. In accepting this arrangement, nan\ee agrees |ohold 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 /> 6�natuie of responsible person) <br /> Bill 1o: <br /> (name) (address) <br /> -----------------------------FOR OFFICE USE ONLY ------------------------------------' <br /> -- - / <br /> C|aso ___-_ | / <br /> Charges: Rental Custodial v <br /> Cooks Other charges: <br /> Note: 7 <br /> ° <br /> wHITE-Community Sorvic"OttlesCopy CANAR,-Dusimoss Otfte Copy PINK-Cuslodans copy ooLo_AP~r9 Copy <br />