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INDEPENDENT SCHOOL DISTRICT NO. 282 <br /> Community Services Department <br /> 3301 Silver Lake Rd 9 St. Anthony, MN 55418 • Phone: 781-5021 <br /> Facilities Reservation Form n�� Permit No. <br /> Name �U s —L C�a Home Phone�� ~ , ;�us. PhonoJTO <br /> Address 1 , Date <br /> Name of Group Or Or antzallon ) ') <br /> Intended Use p <br /> Date(s) wanted A-LL:�, Day(s) Su M T W Th F Sa (circle) <br /> Building: <br /> High School Auditorium <br /> Park View Community Center Cafeteria <br /> Wilshire Park Elem. School Classroom(s) # <br /> Other Gymnasium (If High School, circle one: <br /> OLD NEW ) <br /> Kitchen <br /> Other <br /> Doors to open am pm Expected attendance: <br /> Activity begins '/ m pm Admission: Free Charge <br /> Activity ends am 7, pm Will merchandise be sold? <br /> Special arrangements needed (chairs, cooks. AV equipment, etc ): <br /> 'e�_d <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 resporslblllty 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 representat ves 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 /> BIII lo. <br /> (name) (address) <br /> -------------------------------------- FOR FFICE U ONLY <br /> -------- ----------------------------------------------- <br /> Class Ins Approved by ��% �~ Date 7 " c �l <br /> Charges Rental Custodial <br /> Cooks Other charges <br /> Note: <br /> r <br /> WHITE— Community S4nrk*@ Otac•Copt CANARY— Sullnf►7 O"Ic•Copp PINK— Custodians Copp GOLD—Appllunt'a Copp <br />