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INDEPENDENT SCHOOL DISTRICT NO. 282 Community Services Department I 3301 Silver Lake Rd • St. Anthony. MN 55418 • Phone: 781-5021 Facilities Reservation Form Permit No. Name Home Phone :f Ta 4?a-2 Bus. Phone _2f2-2�* Address _C9 IV711-01V 44A_ Date 019— E 4 Name of Group or Organization Intended Use S4 24C l-l— 64/27Ci Date(s) wanted o - o —� 3 Day(s) Su M T Th F Sa (circle) Building: High School Auditorium Park View Community Center Cafeteria Wilshire P_a_rkfElefn. School Classroom(s) s Other y,' t l i ,r�_Gymnasium (If High School, circle one: OLD NEW ) Kitchen Other 1 . C- k_.1 L - Doors to open am pm Expected attendance: �`<J Activity begins -am- ;*'J�Jpm Admission: _Free Charge Activity ends am / '��_` m Will merchandise be sold? - �,/1� Special arrangements needed (chairs, cooks. AV equipment, etc.): / %i'i.' ��- • 1 hereby certify that I am an agent of the above named group or organization and am authorized to accept in their name the responsibility for observance of the rules and regulations of the Board of Education, Independent School District #282. As a group or organizational agent, I will attend this function,and 1 will be solely responsible forgiving any and all instructions to the custodians or other support personnel.Presentation of this permit to the custodian,on duty is necessary for admittance for the Initial date. In accepting this arrangement, rentee agrees to hold harmless I.S.D. 282 and its representatives from all claims incurred in use of the facility. Rentee waives all rights and claims for potential damages incurred in this rental arrangement. / (signature of responsible person) Bill to: ?;y ,�rJ (name) (address) -----------------------.----------------------FOR OFFICE USE ONLY--------------------------- Class Ins Approved by -' Date Charges: Rental Custodial Cooks Other charges: • `: Note: WHITE—CommuMry septic..Office copy CANARY—Business Office copy PINK—Custodians Copy GOLD—Aopllcenl•.Coor