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INDEPENDENT SCHOOL DISTRICT NO. 282 �, .G•J_ G�C� <br /> Community Services Department <br /> 3301 Silver Lake Rd 9 St. Anthony. MN 55418 • Phone: 781-5021 <br /> Facilities Reservation Form Permit No. �� <br /> Name � '� Home Phone Bus. Phone <br /> Address L10 rd r Today's Date .14143 &4 <br /> Name of Group or Organization 1611,51 1 1 5,- <br /> Intended Use <br /> Date(s) wanted � Day(s) Su M T Th F Sa (circle) <br /> Building: <br /> High School Auditorium <br /> Community Center Cafeteria <br /> Wilshire P_ ark Elem. School Classroom(s) # <br /> Other rr t �►`�A Gymnasium (If High School, circle one: <br /> LARGE SMALL ) <br /> Kitchen <br /> Other <br /> Doorstoopen am pm Expected attendance: <br /> Activity begins am -: .:'l` pm Admission: Free Charge <br /> Activity ends am `' pm Will merchandise be sold? <br /> Special arrangements needed (chairs, cooks, AV equipment, etc.): a <br /> r j � <br /> i ii l <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 ~� ;i ,�•F�i e _� : it i• / %- ��!C- <br /> y Date <br /> Charges: Rental Custodial <br /> Cooks Other charges: • <br /> Note: <br /> WNrTE—CoimnuNly Ssrvkss OMes Copy CANARY—Budnsss Ofte Copy PINK—Cust"am Copy GOLD—Appftmft Copy <br />