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s� <br /> INDEPENDENT SCHOOL DISTRICT NO. 282 <br /> Community Services Department <br /> 3301 Silver Lake Rd • St. Anthony, MN 55418 9 Phone: 781-5021 <br /> Facilities Reservation Form Permit No. 6617 <br /> Name Ml ke+ QVCIA L_f_ t!t k Home Phone -7,11 -q-7-11 Bus. Phone <br /> Address �3C QVf 7 Today's Date <br /> Name of Group or Organization r eL ` <br /> Intended Use Icl r <br /> Date(s) wanted �� ��I c1 Day(s) Su M T W Th Fe (circle) <br /> Building: <br /> High School Auditorium <br /> Community Center Cafeteria <br /> Wilshire Park Elem. School Classroom(s) # <br /> Other A� IV) tJ� a� Gymnasium (If High School, circle one: <br /> LARGE SMALL ) <br /> �r 3 Kitchen <br /> Other //� <br /> Doors to open am pm Expected attendance: L17 r <br /> Activity begins -am /,roe) pm Admission: Free Charge <br /> Activity ends am - "kern 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 /> (signature of responsible person) <br /> Bill to: <br /> (name) (address) <br /> -------FOR OFFICE USE ONLY--- ------------------- <br /> Class Ins Approved - Date <br /> Charges: Rental Custodial <br /> Cooks Other charges: <br /> Note: <br /> r - ft sw%4�cam Ce r"Y&nv_bairn ofies cm mm—mmdnd cm Ootn—""mnh Cam <br />