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INGEPENDENT 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 /> kI /Name �� JU R6�'�l Home Phone Bus. Phone 3 <br /> Address 15�/ 6 TY` ' Date — i <br /> Name of Group or Orga zation v �-�' r t no, <br /> Intended Use Cr7tl <br /> Date(s) wanted Day(s) Su M T W Th F Sa (circle) <br /> Building: <br /> High School Auditorium <br /> Park View Community Center Cafeteria <br /> Wilshire Park Elem. School Classroom(s) # <br /> _Other Gymnasium (If High School, circle one: <br /> OLD NEW ) <br /> Kitchen <br /> Other <br /> Doors to open am pm Expected attendance: 0-5 0 <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 /> 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 r nsible person) <br /> Bill to: i DR. OR MRS. KENNETH H. JOHNSON <br /> { <br /> J-525465-29&126 .l-525-385-071-760 8.157 <br /> ` 3510 SKYCROFT DRIVE 7895912 <br /> MINNEAPOLIS, MINN. 55418 QW� <br />'__-_---_-__� 75-1671/910 <br /> Class PAY TO THE 73— T <br /> t7 <br /> ORD OF <br /> Charge` <br /> I DOLLARS <br /> St.Anthony National Bank • <br /> 2401 Lowry Ave. N.E. <br /> Note: <br /> St. Anth�village, MN 53418 <br /> � _ <br /> - 1:0910 IF, ? 1SI: 203 608511•78 15 ? <br />