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INDEPENDE NT SCHOOL DISTRICT NO. 282 L Gc3-G7 � � Community Services Department 3301 Silver Lake Rd • St. Anthony, MN 55418 • Phone: 781-5021 Facilities Reservation Form Permit No. Name . ,1a- h a Home Phone 789 Bus. Phone Address 353 -,_ �1<y..C�'a.�t�r' Today's Date 7 z- `7_3 Name of Group or Organization Intended Use t ��ei 'elC n rc Date(s) wanted i ; / - Day(s) Su f6W F Sa (circle) Building: '7 High School Auditorium Community Center Cafeteria Wilshire Par l Elem. School Classroom(s) # Other �. r Gymnasium (If High School, circle one: LARGE SMALL ) Kitchen Other ,y Doors to open am pm Expected attendance: y Activity begins am pm Admission: Free Charge Activity ends am 1,.--pm Will merchandise be sold? Special arrangements needed (chairs, cooks, AV equipment, etc.): I hereby certify that I am an agent of the above named group or organization and am authorized to accept in their name the responsibility for observance of the rules and regulations of the Board of Education, Independent School District #282. As a group or organizational agent,I will attend this function,and I will be solely responsible for giving any and all instructions to the custodians or other support personnel.Presentation of this permit to the custodian on duty is necessary for admittance for the initial date. In accepting this arrangement, rentee agrees to hold harmless I.S.D. 282 and its representatives from all claims incurred in use of the facility. Rentee waives all rights and claims for potential damages incurred in this rental arrangement. � sin t l f n i l (s s a u e• r s'• s�e'erson)Ck Bill to: (name) (address) ---------------------------------------------- FOR O ICE USE ONLY------------------------------------------------- Class Ins Approved Date — 1;?Charges: Rental Custodial Cooks Other charges: 7 F Note: WHITE—Community services Office Copy CANA Y—Business Office Copy PINK--Cu�tod Copy GOLD—Applicant's Copy -