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INDEPENDENT SCHOOL DISTRICT NO. 282 <br /> Community Services Department <br /> 3301 Silver Lake Rd o St. Anthony, MN 55418 • Phone: 781-5021 �. <br /> Facilities Reservation Form Permit No.• �Z <br /> ;. <br /> Name ' Home Phone Bus. Phone ' <br /> ; <br /> Address ' �' Today's Date <br /> Name of Group or Organization AP- <br /> Intended Use <br /> Date(s) wanted Day(s) Su M T WiTti�F Sa (circle) <br /> Building: <br /> High School Auditorium <br /> Community Center Cafeteria <br /> Wilshire Park Elem. School Classrooms) # <br /> Other Gymnasium (If High School, circle one: <br /> r j-,-� LARGE SMALL ) <br /> f i Kitchen <br /> ! <1 ;_ :���i'C{ Other <br /> Doors to open am pm Expected attendance: <br /> Activity begins am pm Admission: �i:5� Free Charge <br /> Activity ends am,/ pm Will merchandise be sold? <br /> Special arrangements needed (chairs, cooks, AV equipment, etc.): <br /> . C <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. r <br /> (signature of responsible person) <br /> Bill.to: <br /> (name) (address) <br /> FOR OFFICE USE ONLY ------------------------------------ <br /> Class Ins Approved by 1 / � I ! t fr f , Hate <br /> Charges: Rental Custodial <br /> Cooks Other charges: <br /> Note: A.,( =' / . �.. ,: ..r . ! ✓ ,.., (. !�t ( ..J` .. / . 'l / ,. � , .. rt. <br /> WHITE—Community Services Olfleo Copy CANARY—Business Offk*Copy PINK—Cudodimm Copy GOLD—Apptkent's Copy <br />