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9-7 } ` - rm . . <br /> -- INDEPENDENT SCHOOL DISTRICT NO. 282 <br /> Community Services Department <br /> _ 3301 Silver Lake Rd • St. Anthony, MN 55418 • Phone: 781-5021 <br /> Facilities Reservation Form <br /> Permit No. <br /> r <br /> :_' iJ+J� 1 -<<;-- Home Phone ' b ( Bus. Phone Y�-��� <br /> Name � _ <br /> Address• <br /> Date ' - <br /> Name of Group"or Org tion I- <br /> Intended Use r C 1 I <br /> Date(s) wanted �' �� ! �� I Day(s) Su M Th F Sa (circle) <br /> Building: <br /> High School Auditorium <br /> Park View Community Center Cafeteria <br /> Wilshire Pafk Elem. Schoolr 'Ir Classroom(s)slum # g <br /> Othe��' G m slum ( f High School, circle one: <br /> ,,,�.- { ,�. j OLD NEW <br /> ��" <br /> z Other - <br /> Doors to open am pm Expected attendance: <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 1 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 1 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 thi angemsDI,rentee agrees to hold harmless <br /> I.S.D. 282 and its representatives from all claims incurred in use oft fa lity.R�6nte 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 />------------ --------------------------------FOR�OFFICE/USE ONLY---------------------------°"""""""- <br /> Class Ins Approved by —� �!'ft! • J i /����� Date <br /> Charges: Rental Custodial <br /> Cooks Other charges: <br /> Note: t � . �.,:_- � _ .�,Y� .-y l..�� �� .!'ri•�i <br /> p e,pl <br /> !"� ( ' _ ,rry s.Me..omu covr w r�Wiliam$•onk.co" PINK—amoew COPY oo�c—Mv��ri cenr <br />