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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 /> J i <br /> Name . / -i ,� - <br /> Home Phone �.6 / lBus. Phone <br /> Address �� `% '� Ff;.l- Today's Date r` Z/ <br /> Name of Group or Organization <br /> Intended Use - r! f} l �' L�% <br /> Date(s) wanted. <br /> Day(s) Su M T W Th F%;- (circle) <br /> Building: <br /> High School Auditorium <br /> Community Center Cafeteria <br /> Wilshire Park Elem. School Classrooms) # <br /> Other r1 _ �U Gymnasium (If High School, circle one: <br /> " - �..',`} , r,, LARGE SMALL ) <br /> (- ^)T L Kitchen <br /> Other <br /> Doors to open am pm," Expected attendance: <br /> Activity begins •�.j1, ',2A)am pm Admission: Free Charge <br /> Activity ends -am <br /> 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 t0: <br /> (name) (address) <br />----------------------------------------------FOR OFFICE USE ONLY <br /> Class Ins Approved by'" s ( .�* i%lt .��-L_, Date ' <br /> Charges: Rental / Custodial <br /> Cooks Other",charges: • <br /> Note: <br /> WHITE—Community services Office Copy CANARY—Business Office Copy PINK—Custodians Copy GOLD—Applicant's Copy <br />