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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 /> Name �� iY) ire V e-y- Home Phone �c 3 Bus. Phone 339 , 02� <br /> Address 71 / = 1- TTl"1j77L i-i , vd, Date c�; <br /> Name of Group or Organization Y ,* //nq e �t�S 7� <br /> Intended Use -a Q7 Z-_-k) r 6 417 <br /> Date(s) wanted 04 - r— r Day(s) Su M T W Th Sa (circle) <br /> Building: <br /> High School Auditorium <br /> Park View Community Center Cafeteria <br /> Wilshire Park Elem. School Classrooms) ft <br /> —Other _ _ Gymnasium (If High School, circle one: <br /> OLD NEW ) <br /> Kitchen <br /> h Other <br /> Doors to open am pm 1, -1 t,-i'c(4i r h tExpected attendance: <br /> begins am S�+ <br /> Activit L(�a l {zYZ <br /> Y g pm L t(L Admission: _Free Charge <br /> Activity ends am pm 7- ? Will merchandise be sold? :6- <br /> Ill t `el hp-1 <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(or the initial date. In accepting this arrangement, rentee agrees to hold harmless <br /> I.S.D. 282 and I;s representatives from a'11 claims incurred in use of the facility. Rentee waives all rights and claims for <br /> potential damages incurred in this rentl arrangement. <br /> i_.e.e_ <br /> (signature of responsible person) <br /> Bill to: <br /> (name) (address) <br />----------------------------------------------FOR OFFICE USE ONLY------------------------------------------------- <br /> Class Ins Approved by Date <br /> Charges: Rental Custodial <br /> Cooks Other charges: • <br /> Note: <br /> WHITE—Community Services Office Cool CANARY—Business Office Coot PINK—Custodians Cool GOLD—Applicant'.Cool <br />