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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 Permit No. <br /> Name 1� Ea325 AA Home Phone Bus. Phone7& a-73�'O • <br /> Address 26 L Ul WLR - Date. <br /> Name of Group or Organization <br /> Intended Use ISO <br /> Date(s) wanted rrj UJ14 Day(s) Su M T W Th ©Sa (circle) <br /> Building: <br /> High School Auditorium <br /> Park View Community Center Cafeteria <br /> Wilshire Park Elem.. School — <br /> Classroom(s) # <br /> Other CM• �� PT1s�����^-�� t `c� Gymnasium (If High School, circle one: <br /> a,.d s�-ba�� F►�Qd �ye5� OLD NEW ) <br /> Kitchen <br /> Other <br /> Doorstoopen am pm Expected attendance: /5G�•,- <br /> Activity begins am 4,00 pm Admission: Free Charge <br /> Activity ends am /'�:00 pm Will merchandise be sold? /VO <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 fa " it Rentee waives all rights and claims for <br /> potential damages incurred in this rental arrangement. <br /> i <br /> (signatut V <br /> responsible person) <br /> Bill to: <br /> (name) (address) <br /> _----FOR-OFFICE USE ONLY---------------------- <br />---------------------------------------- --------------------------- <br /> Class Ins Approved by Date <br /> Charges: Rental Custodial <br /> Cooks Other charges: • <br /> Note: <br /> wNITa—cmnnnunity Services Office copy CANARY—13u sines*Office copy PINK—Custodians Copy GOLD—Apptkant'a COPY <br />