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e <br /> cc <br /> INDEPENDENT INDEPENDENT SCHOOL DISTRICT NO. 282 <br /> Community Services Department <br /> 3301 Silver Lake Rd a St. Anthony, MN 55418 • Phone: 781-5021 <br /> Facilities Reservation Form Permit No. ��7 ^• <br /> Name 4 Qi" Home Phone V6425 Bus. Phone <br /> Address —7 4+ U 1 '> +� I T Aj, Today's Date b C <br /> Name of Group or Organization S.,\ C <br /> Intended Use <br /> Dale(s) wanted -b— ��— Cl j 4-1 p•M► Day(s) Su M 1G Th F Sa (circle) <br /> Building: <br /> High School Auditorium <br /> Community Center Cafeteria <br /> Wilshire Park Elem. School Classrooms) If <br /> Other Gymnasium (If High School, circle one: <br /> ` t _ LARGE SMALL ) <br /> "�' C,Ca..n't C'c�-1 3 �.�`FtC�-� Kitchen <br /> Other <br /> Doors to open am pm Expected attendance: <br /> Activity begins am U pm Admission: Free Charge <br /> Activity ends am /'eGpm 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,l 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 /> Q` C <br /> (signal re of responsible per <br /> Bill to: <br /> (name) (address) <br />----------------------------------------------FOR O EICE USE ONLY------------------------------------------------- <br /> Class Ins Approved by - Vb ' < Gkk-cL.- Date �1 <br /> Charges: Rental Custodial <br /> C oks - Other charges: <br /> Note: / ._ .�1 f tic - ±L• = 1� .f L�` t��i` <br /> WHIn-camarAft ftiV"ON"cove► CAMAAY ftd, ._Dina - <br /> , ceor Prrat 'cu.foa.n.coon ooLo _AOpnunn coon <br /> -�r <br />