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INDEPENDENT%CHOOL DISTRICT.NO. 282 <br /> tonmmunity Services Department <br /> 3301 Silver Lake Rd St. Anthony, MN 55418 • Phone: 781-5021 <br /> Facilities Reservation Form Permit No. 3-3 <br /> Name _s 1�11� _C —� (_(,lG�� h Home Phone7_Yy_-b2,5M2,Bus. Phone — �- <br /> Address -�� �l�e Date - <br /> Name of Group or Organization ` <br /> �, <br /> Intended Use <br /> UA) ,­Aros <br /> Date(s),wanted Day(s)OM T W Th F Sa (circle)'' <br /> Building: <br /> High School Auditorium <br /> Park View Community Center Cafeteria <br /> Wilshireark EI School Classroom(s) # <br /> Other. - Gymnasium (If High School, circle one: <br /> Cc— <br /> f �� ��•r�IC OLD NEW ) <br /> Kitchen <br /> Other <br /> Doors to open am pm Expected attendance: <br /> Activity begins am pm Admission: Free Charge <br /> Activity ends am pm Will merchandise be sold? ks, <br /> Special arrangements needed (chairs, cooks, AV equipment, etc.): <br /> 'J <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, 1 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 /> BIII to: <br /> (name) (address) <br />------------------------------------------------FOR OFFICE USE ONLY-----------------------------f-------------------- <br /> Class Ins Approvedbyiii-mac , Date <br /> Charges: Rental . Custodial <br /> • Cooks Other charges: <br /> Note: <br /> WHITE—Community Services Office Copy CANARY—Business Office Copy PINK—Customers Copy GOLD—Applicant's Copy <br /> rs <br />