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INDEPENDENT SCHOOL DISTRICT NO. 282 <br /> Community Services Department <br /> 3301 Silver Lake Rd • St. Anthony, MN 55418 0 Phone: 781-5021 <br /> Facilities Reservation Form Permit No. ," <br /> Name Home Phone �'7J Bus. Phone <br /> Address V � t-`'�� Today's Date <br /> Name of Group or Organization <br /> Intended Use -� -� <br /> Date(s) wanted / Day(s) Su M T W 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 /> LARGE SMALL ) <br /> Kitchen <br /> Other <br /> Doors to open am pm Expected attendance: <br /> Activity begins am pm Admission: Free Charge <br /> Activity ends am pm 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 forgiving <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: j - '.- ` 6-7 <br /> (name) (address) <br />---------------------------------------------FOR OFFICE USE ONLY--------------------------- ------------------- <br /> Class Ins Approved by •X �"�-� �- �_- -��f�---+ Date � o <br /> Charges: Rental Custodial <br /> Cooks Other charges: <br /> Note: 'r ' .;� ��� �1.�•�'� %� �i�`y� � j2 c�...:�1. t�..0 /= t,• ���i� <br /> , <br /> WHITE—C --urdh 6mkM onke Caar cAmARY—Surge"oMloe ca" viHx �foaoer Coor aoC —Aoonc.r+re cover <br />