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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 Home Phone -D,10,1 Bus. Phone 3 1r; ' 35V <br /> Add ress t. Today's Date :x <br /> Name of Group or Organization i t <br /> Intended Use �!")..i !_. t , rt ,.` <br /> Dated' t1_l )D _ c <br /> . (s wante) � Day(s) Su M T W Th Fa (circle) <br /> Building: <br /> High School Auditorium <br /> Community Center Cafeteria <br /> Wilshire ark E Scrpol Classroom(s) # <br /> Other t y1 t Q rL-, Gymnasium (If High School, circle one: <br /> LARGE SMALL ) <br /> Kitchen <br /> Other <br /> Doors to open 'am pm Expected attendance: o <br /> fin . <br /> Activity begins I I &--am pm Admission: Free Charge <br /> Activity ends am • b Opm Will merchandise be sold?. <br /> Special arrangements needed (chairs, cooks, AV equipmen3, etc.):' <br /> I hereby certify that I am an agent of the above name r.�p 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. t <br /> -1 i <br /> (signature of r sponsible person) <br /> Bill to: <br /> (name) (address) <br />---------------------=-----------------------FOR OFFICE USE ONLY------------------------ <br /> ------ _------- <br /> Class ns Approved by Date <br /> Charges: Rental Custodial <br /> oks Other charges: <br /> Note: L_ec Z:.`.e '"Z.Lf <br /> WNire-Community Services Office copy CANARY-eaanme office copy PINK-Cmtomam copy 601.0-Appliunre copy <br />