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INDEPENDENT SCHOOL DISTRICT NO. 282 <br /> Community Services Department <br /> 3301 Silver Lake Rd a St. Anthony, MN 55418 • Phone: 781-5021 <br /> Facilities eservstion Form Permit No. <br /> Name ��Home Phone 7iV-141(r, Bus. Phone 37 q CX4 <br /> Address_ ` _ Date 3 <br /> Name of Group or Or anization _ �� <br /> Intended Use <br /> Date(s) wanted _ _ _ Day(s) Su M T W ThOF Sa (circle) <br /> Building: <br /> High School __Auditorium <br /> Park View Community Center Cafeteria <br /> Wilshir ark Elem. Sc000l Classroom(s) # <br /> Other :� Gymnasium (If High School, circle one: <br /> OLD NEW I'�yCc.GLCt�J i <br /> Kitchen <br /> Other <br /> Doors to open _am pm Expected attendance: <br /> Activitybegins _am,���'__pm Admission: __Free Charge <br /> Activity. ends --- am t pin Will merchandise be sold? <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 facility. Rentee waives all rights and claims for <br /> potential damages incurred in this rental arrangement. <br /> r <br /> (signature if r sponsible person) <br /> Bill to: <br /> (name) (address) <br /> ------------------=--------------=-----------FOR OFFICE USE ONLY--------------------------------=---------- <br /> Class Ins Approved by ff• t- Date <br /> Charges. Rental Custodial <br /> Cooks Other charges: • <br /> Note: <br /> WHITE—Community Semb umo.CAP1 —4••-Irws olrta Copy PINK—CuebdI=w Capt' GOLD—AppGcmft Copy <br />