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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 Permit No. <br /> Name Home Phone _ZJ_`' "�', �Ius. Phone <br /> Address Today's Date <br /> Name of Group or Organization CA <br /> ' <br /> Intended Use -v <br /> 6 <br /> Date(s) wanted Day(s) Su M T W t1i F Sa (circle) <br /> Building: <br /> -High School -Auditorium <br /> -Community Center -Cafeteria <br /> -Wilshire Park Elem. School -Classroom(s) # <br /> -Other -Gymnasium (if High School, circle one: <br /> LARGE SMALL <br /> -Kitchen <br /> -Other <br /> Doors toopen am pm Expected attendance: <br /> Activity begins _ar%_pm Admission: -Free Charge <br /> Activity ends -am--prn Will merchandise be sold? <br /> Special 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 N <br /> .X!s arrangement, rentee agrees to hold harmless <br /> I.S.D. 282 and its representatives from all claims incurred in use OT the•facility.Rentee waives all rights and claims for <br /> potential damages incurred in this rental arrangement. <br /> J <br /> V(signature of responsible person) <br /> Bill to: <br /> (name) (address) <br /> ----------------------------------------------FOR OFFICE USE ONLY-------------------------------------------------; <br /> Class Ins Approved by L' Date <br /> Chardes: Rental Custodial <br /> ".Cooks Other charges: <br /> 71,4L.) <br /> --Llo YA <br /> WHITE—Community So v se Office COPY CANARY—Business Office Copy PINK—Cusl*dans Copy GOLD—Appikenris cm <br />