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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 /> t <br /> 4kame (7 r��i;_j, i e i Home Phone Bus. Phone <br /> Address Date b <br /> Name of Group or Organization <br /> Intended Use <br /> "(circle) <br /> Date(s) wanted'�j Day(s) Su M T W Th F,'Sa <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 —prn Expected attendance: <br /> Activity begins —am —prn Admission: —Free Charge <br /> Activity ends am pm Will merchandise be sold? <br /> Opecial arrangements needed (chairs, cooks, AV equipment, etc.): <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. Rent.ee waives all rights and claims for <br /> potential damages incurred in this rental arrangement. <br /> (sigrfature of responsible person) <br /> Bill to: <br /> (name) (address) <br /> ----------------—----------------------------FOR OF FICE USE ONLY--------------------- <br /> Class Ins Approved by Date <br /> Charges: Rental Custodial <br /> Cooks 6ther charges: <br /> Note: <br /> WMMI—Cowdwi"Sm It OMM Copy CAMAT—Musinm 0Mn Coy FtMX—CuslmdMm CM OOLD—Appllwft Co".-_. <br />