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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 ormm Permit No. - <br /> Name Home Phone <br /> v�73/Bus. Phone <br /> QLSa <br /> Address Today's Date <br /> Name of Group or Organization <br /> Intended Use <br /> Date(s) wanted f ' �`.� 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._ ._ _,_ _ _ _ _ __ Classroom(s)-# <br /> _r <br /> Other - Gymnasium (if High School, circle one: <br /> LARGE --.SMALL )- - <br /> --- - Kitchen <br /> Other <br /> Doors to open ff am pm Expected attendance: <br /> Activity begins am pm Admission: Free Charge <br /> Activity ends am pm- j> r► 1< Will merchandise be sold? <br /> Special arrangements needed (chairs, cooks, AV equipment, etc.): �f:-t` .< ,- 1/12 <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 /> 1 1 <br /> (signature of responsible person) <br /> Bill to: <br /> (name) (address) <br />---------------------------------------------FOR OFFICE USE ONLY------------------------------------------------- <br /> Class Ins Approved by -f'_`t `' `"fDate� <br /> Charges: Rental Custodial'- <br /> . � <br /> Cooks Other charges: <br /> Note: <br /> ......-- ._��.. .u.�w--.. PAUADW—s..­1 . d. Pamir—n..wr....r,...v Anobefinr.Cww <br />