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INDEPENDENT SCHOOL DISTRICT NO, 282 <br /> Community Services Department . <br /> 3301 Silver Lmhe Rd * St. �mNhomy. MN 55418 o Phone: �8� 50211 <br /> Facilities Reservation Form Permit No. <br /> __-_-___' <br /> Name ���-�,-^ / / _- / /`^ �- -___--_-_- HomePhono�/-����.7�'-T-/� Buu� Phone �/�_.��L3��'^- <br /> - <br /> Address . c�/ / <br /> Name o( Group orOrganizatinn <br /> �� Fh /~ x l/ /~ <br /> |ntendedUso -_-���L��_�����<-�-��,��^^ ' ' ' ` ' ' -- ' -��--------'-------- <br /> "c 7 <br /> T' / / <br /> Date(s) wanted Ooy<a) �u �� T VV T� FVSa (oirda) <br /> ___ � <br /> Building: <br /> _--_-High School -Auditorium <br /> -Park View Community Center --_-_Cafp\erim <br /> -Wilshire Park Elem. School Classroom(s) # <br /> -__-'O\ho, -Gymnasium <|f High Schoo|, circle one: <br /> OLD NEW <br /> --Kitchen <br /> \her -~ -`. <br /> Ooorstnopen __---_am __pm Expected attendance: <br /> Activity begins -�72V um _-__---pm Admission: ____'Fnoa Charge <br /> Activity ends -am X__l_?Qpm Will merchandise be oo|d <br /> J�� <br /> Special arrangements needed (chairs, cooks. AV equipment, etc.): ^'�� ~ ' - -- ~� <br /> � <br /> , <br /> � <br /> | hereby certify that | am an agent of the above named group ororganization 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 e group or organizational agent. | will attend this function, and |will be solely responsible for giving <br /> any and all instructions to the custodians or other support personnel. Presentation mYthis permit to the custodian on <br /> duty is necessary for admittance for the initial date. |n accepting thi rrangement, rentee ag es to hold harmless <br /> I.S.D. 282 and its representatives from all claims incurred in userhe facility. entee w ves al"righ1s and claims for <br /> potential damages incurred in this rental arrangement. <br /> � (monam/em responsible P-Vr,nn) ` <br /> Bill /o: ' <br /> (namc} (address) � <br /> / <br /> ---------------------' FOR OFFICE USE ONLY - -- <br /> C|auo_ ins Approved by Date <br /> Charges: Rental Custodial <br /> 'I Cooks Other charges: <br /> Note: ____-_------_-_ <br /> WHITE-Community Services Office COPY CANARY-o"^~°"office Copy mw^-c^"!iumans Cop, GOLD-Applicant's Copy <br />