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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 �S ! Permit No. <br /> Name Home Phone v Bus. Phone <br /> Address Toda y's Date <br /> Name of Group or Organization f <br /> Intended Use <br /> Date(s) wanted ` ,� - - Day(s) Su M T W Th F Sa (circle) <br /> t <br /> Building: <br /> High School Auditorium <br /> Community Center Cafeteria <br /> Wilshire Park Elem. School �` Classroom(s) # <br /> Other�rLC- � �1 , Gymnasium (If High School, circle one: <br /> L L• d to L. (� S LARGE SMALL ) <br /> _ Kitchen <br /> 1 ,l1 F 1 CC, LA I.-, Other <br /> fi)/1 Ll6AJ <br /> Doors to open am pm , Expected attendance: <br /> Activity begins am`''""` L Admission: Free Charge <br /> Activity ends am -`pm' Will merchandise be sold? <br /> 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 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 clai s for <br /> potential damages incurred in this rental arrangement. <br /> ( gnature of reap person) <br /> Bill to: <br /> (name) (address) <br />----------------------------------------------FORkC <br /> fflFtCE USE ONLY--------------------------- --- --------- <br /> �/% <br /> Class Ins Approved by Date <br /> j <br /> Charges: Rental Custodial <br /> Cooks Other charges: <br /> Note: <br /> WHITE—Cam MnIty 86rikes Office Cagy CANARY—audma Otft*Copy PINK—Cuutodimm Copy GOLD—Applkann copy <br />