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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 Permit No. <br /> Name Home P h o n e -7 1V 71,7tus. Phone -'I <br /> -7' <br /> Address 4-l" Today's Date <br /> Name of Group or Organization <br /> Intended Use <br /> Date(s) wanted Day(s) Su M T W Th F Sti (circle) <br /> Building: <br /> -High School Auditorium <br /> -Community Center -Cafeteria <br /> -Wilshire-Park Elem. Schooll -Classroom(s) # <br /> -Other % <br /> Gymnasium (if High School, circle <br /> LARGE SMALL <br /> Kitchen <br /> Other <br /> Doors toopen -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 /> 14 4? <br /> X, <br /> 7 <br /> 61 <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 />---------------—-------------------------- <br /> FOR USE ONLY--------------------------------- <br /> Class Ins Approved by I ;, <br /> Date <br /> Charges: Rental Custodial' <br /> Cooks Other charges: <br /> Note: li 40C <br /> WHIII`11—Comwilty Sftv$m Offlee Cer 1Y—SusIneen^I%*Copy PINK—CusWellmn Copy GOLD—Applicenre Copy <br />