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INDEPENDENT SCHOOL DISTRICT NO. 282 <br /> Community Services Department <br /> 3301 Silver Lake Rd • St. Anthony, MN 55418 • Phone: 781-5021 <br /> Facilities Reservation Form Permit No. <br /> Name Home Phone Bus. Phone <br /> Address Date <br /> Name of Group or Organization <br /> Intended Use 4 > <br /> Date(s) wanted f r Day(s) Su M T W Th F Spa} (circle) <br /> Building: <br /> High School Auditorium <br /> Park View Community Center Cafeteria <br /> Wilshire Park Elem. School Classroom(s) # <br /> Other zT t L. .� tT� Gymnasium (If High School, circle one: <br /> OLD NEW ) <br /> Kitchen <br /> ` Other <br /> Doors to open am ipm Expected attendance: <br /> Activity begins am pm Admission: --X—Free Charge <br /> Activity ends —aml pm Will merchandise be sold? <br /> Special arrangements needed (chairs, cooks, AV equipment, etc.): <br /> 1 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 person) <br /> Bill to: <br /> (name) (address) <br />-----------------------------------------------FOR OFFICE USE ONLY------------------------------------------------- <br /> Class Ins Approved by Date <br /> Charges: Rental ' Custodial <br /> Cooks Other charges: <br /> Note: <� �, .s p--;4-.r a– <br /> WHITE—Community Services Office,Copy CANARY—Business Office Copy PINK—Cudo ans Copy GOLD—Applicant's Copy <br />