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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 34r=30E�us. Phone <br /> Address '7 - Today's Date ' <br /> Name of Group or Organization ?« ' act <br /> i <br /> Intended Use <br /> Date(s) wanted l - 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) # <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 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 by /•-�' •y ' - �- `�' ��� �/ Date <br /> Charges: Rental Custodial <br /> Cooks ! Other charges: <br /> Note: <br />