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INDEPENDENT SCHOOL DISTRICT NO. 282 <br /> Community Services Department <br /> 3301 Silver Lake Rd u St. Anthony, MN 55418 Y Phone: 781-5021 <br /> Facilities Reservation Form Permit No. <br /> Name — ra MI � �l Home Phone l(1��SS1'l. Bus. Phone <br /> Address <br /> Name of Group or Organization ti--( 1. \ C nv 041 >1' —!1 ,t `d� ��'�'Lt'�'` <br /> Intended Use �-fi`� 1 ., 1 � , Qk&---L <br /> Date(s) wanted _� ``t _t l—�•! __ _.___.._____ Day(s Su M T W Th Sa (circle) <br /> Building: <br /> High School Auditorium <br /> -.—Park View Community Center Cafeteria <br /> Wilshire Park Elev. Schopl Classrooms) 9 <br /> Other "WX ___Gymnasium (If High School, circle one: <br /> OLD NEW ) <br /> Kitchen <br /> Other _. l ' . <br /> Doors to open �L_am _pm Expected attendance: "— <br /> Activity begins am _-pm Admission: ___Free —X--Charge <br /> Activity ends —7-am ---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 forgiving <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 facility. RenteeIves all rights and claims for <br /> potential damages incurred in this rental arrangement. <br /> (siggnatu�ree o1 res/pJon�w le person) <br /> Bill to: C e— <br /> (name) (address) <br /> ---------------------------------------------FOR OFFICE USE ONLY-------------------------------- ------ <br /> Class Ins Approved by Date <br /> Charges: Rental Custodial <br /> Cooks Other charges: <br /> Note: <br /> WHITE—Community Semites Office Copy CANARY—Business Oftice Copy PINK—Custodlens Copy GOLD—Applicant's Copy <br />