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INDEPENDENT SCHOOL DISTRICT NO. 282 <br /> Community Services Department <br /> 3301 Silver Lake Rd III St. Anthony, MN 55418 a Phone: 781-5021 <br /> Facilities Reservation Form Permit No. <br /> 1 L <br /> Name `� c �` \ -: L)^��- ` Home Phone 4 (r Bus. Phone <br /> Address ` r. ; : �' t-t �1�- G Today's Date <br /> Name of Group or Organization -� '� X <br /> Intended Use l I ► ' < ►� Y r ' t <br /> Date(s) wanted "' - Days) Su M T W Th 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 /> LARGE SMALL } <br /> f Kitchen <br /> Other <br /> Doors to open am pm Expected attendance: <br /> Activity begins am1•�'lpm Admission: Free Charge <br /> Activity ends am q, 0pm Will merchandise be sold? <br /> Special arrangements needed (chairs, cooks, AV equipment, etc.): • <br /> hereby certify that I am an agent of the above named group or organization and am authorize6to accept in their <br /> name the responsibility for observance of the rules and regulations of the Board of Education, Independent School <br /> District 6282. 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 /> I ' <br />----------------------------------------------FOR OFFICE USE ONLY------------------------------------------------- <br /> Class Ins Approved by i - -A-e�-' Date <br /> Charges: Rental Custodial <br /> Cooks Other charges: • <br /> Note: L. 61._(.:-�✓ i'.:.�.. �.. <br /> U. <br /> WHITE—Cqn eunity,IL'office Copy CANARY—Sushwi.OMU Copy 'PINK—CustoNans Copy OLD—Applicant's Copy l- <br />