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~; d <br /> r <br /> I <br /> INDEPENDENT SCHOOL DISTRICT NO. 282 <br /> Community Services Department <br /> 3301 Silver Lake Rd • St. Anthony, MN 55418 • Pho : 781-5021 • <br /> -z f Facilities Reservation Form Permit No. <br /> Nam Home Phone 07S <br /> Bus. Phone-132- -� M <br /> „n Address d v Date <br /> Name of'Group or Organization <br /> Intended Use �c r� j <br /> " Date(s) wanted Day(s) Su M T W Th Sa (circle) <br /> r. . <br /> Building. <br />-` High School Auditorium <br /> Park View Community Center Cafeteria <br /> Wilshire ark Elem. Schoo Classroom(s) #Other P.-n��Y �i►- ��_,,..,....,( <br /> .j <br /> Gymnasium If High Y ( g School, circle one: <br /> OLD NEW ) <br /> Kitchen <br /> Other <br /> Doors to open am pm Expected attendance: <br /> Activitybegins �/ am qq pm Admission: Free Charge <br /> Activity ends am __L m ? • <br /> P Will merchandise be sold. <br /> Special arrangements needed (chairs, cooks. AV equipment, etc.): C 6L y f 94- <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 /> °•; - (signatwe of responsible a on) <br /> Bill to.' <br /> (name) <br /> (address) <br />--------- -- _-w_- --------- ---FOR OFFICE USE ONLY--------------------------------- <br /> Class Ins Approved by Date <br /> Charges: Rental /��� • <br /> Custodial <br /> • Cooks Other charges: <br /> Note: <br />