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INDEPENDENTS SCHOOL DISTRICT NO 282 <br /> Community Service:.Department <br /> 3301 Silver Lake Rd.* St. Anthony, MN 55418.o Phone: 781-5021 <br /> - Facilities.Reservation Form Permit No. <br /> Name. (4"a L 4:-.- i A ,Home Phone - =Bus. Phone <br /> Address t3 n/ ' Date <br /> Name of Group or Organization g�� 1' ✓� �� �i <br /> Intended Use Z.A.4 <br /> a <br /> Date(s) wanted Day(s) S. M T W Th F Sa (circle) <br /> Building: <br /> High School Auditorium <br /> Park View Community Center Cafeteria <br /> Wilshire Park EJem. Sc�iool Classrooms) # <br /> Other j t',r li,�� ! �- Gymnasium (If High School, circle one: <br /> OLD NEW ) <br /> Kitchen <br /> Other <br /> Doors to open am pm Expected attendance`. 7s, <br /> Activity begins —I am pm Admission: Free Charge <br /> Activity ends am L 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 responsible person) <br /> Bill to: <br /> (name) (address) <br />---------------------------------------------- <br /> FOR OFFICE USE ONLY------------------------------------------------ <br /> Class Ins Approved by Date <br /> Charges: Rental Custodial <br /> Cooks Other charges: <br /> Note: <br /> WHIT!—Conrnunity fwvlc"Onto Copp CANARY—Sudntirr OMa Copy PINK—Cuslodrrnt Copy GOLD—Applicant's Copy <br />