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DISTRICT NO. 2082 <br /> INDEPENDENT SCHOOL <br /> community services Department <br /> S021 <br /> 001 Sliver Lake Rd * St. Anthony, MN 55419 9 Phone: 781 <br /> Facilities Reservation Form Permit No. <br /> Y —us. Phone-:� <br /> am IC tA ":A ("I E-12 L EF Home Phone <br /> Address 7- A';,R Date <br /> �ev't C <br /> Name of Group'.or Organization e P`/M T<7 Al <br /> intended Use i I C <br /> Date(s) wanted Day(s) Su M T W Th "a (circle) <br /> Building: <br /> —High School —Auditorium <br /> ' Park View Community Center —'Cafeteria <br /> —Wilshire Park Elem. School —Classroom(s) # <br /> 0 t h e r P%L_ 'ft g.r"t-' —Gymnasium (if High School, circle one: <br /> OLD NEW <br /> —Kitchen <br /> Other <br /> Doors to open --am _pm Expected attendance: <br /> Activity begins.�-L,/ C' am pm Admission: —Free- Charge <br /> Activit <br /> y ends —am pm Will merchandise be sold? <br /> pecial arrangements needed (chairs, cooks. AV equipment, etc.); C. J <br /> 1 F 7% -7 1 F-T <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 Educatiorf. 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 f rom all claims incurred in use of the facility.Rentee waives all rights-and claims for <br /> potential damages incurred in this rental arrangement.---.-.. <br /> 4 <br /> tsignatumotfesponsibi gerson <br /> feddirii <br /> narne <br /> USE.0 <br /> FOK-OFFICE. NLY <br /> ------------ -------- <br /> ins App ate V - _ez <br /> Cliss irove y. <br /> 777--- <br /> Charges:- Rental ustodial <br /> Q poks Other charges: <br /> 140te: -7L 4� r _cl <br /> W I kie --I po� OOLD Z6 Appk-�Co" <br /> ftedn64 omc�p c"M- PINK <br />