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INDEPENDENT SCHOOL DISTRICT NO. 282 <br /> Community Services Department <br /> 3301 Silver Lake Rd 0 St. Anthony, MN 55418 • Phone: 764-50.11 <br /> Facilities Reservation Form Pe-mit No. <br /> :arae '• ,�-�.�� %,.-� dome Phone 7--al 5o 75Bus. Phone ._•�r -/= <br /> Aodre55 2 O Date <br /> too, U <br /> Name of Group or Orgarization <br /> Intended Use <br /> % r7 r i 1 D° (S Su h^ I 11" h F Ca (circlF.) <br /> Date(s) wanted �-�--� _ �• � - �Y, ) r✓ <br /> Building: <br /> High School Auditorium <br /> dark view Community Center Cafeteria <br /> Wilshire Park Elern. Sc.hoo! __Ciassroom(s) <br /> �C—Other L!el r--'2_ v __-ymnasium (If High School, circle one. <br /> OLD ' <br /> ra. Kitchen <br /> Ot`:2r <br /> Doors to open am pm Expected attendance: <br /> Activity begins am 3 ppm Admission: Free Charge <br /> Activity ends ami r--m Wil! merchandise be sold? <br /> Special arrannemen;s needed (c'-airs, cooks: AV equiprnent, etc.): <br /> I hereby certify th?; I am an anent of the above named group cr organizction and am authorized to accept in their <br /> r arae the resnonsibilay for bt-servanne of the rules and regulations of the Board of Educati':�r. Independent Schco: <br /> District x252. As a group or organizational agent, I will attend this function,anS I wil: be solely responsible for g'.vin_; <br /> any and all instructions to the custodians or other support person.-W. Presenia Con of this permit to the custodian on <br /> duty is necessary for admittance for the initial date. In accepting this arrangement. rentee agrees tc ho!d harmless <br /> I.S.D. 284" and its representatives from all claims incurred in use of the faci!:'y. Rentee waives all rights ar+d claims for <br /> potential damages incurred in his rental arrangement. � <br /> (s,gnawte o1 <br /> Bill to: — <br /> '5rri[,' la-:rebSj <br /> FOR OFFICE USE ONLY ----------------------------Class Ins <br /> Approved ty =" z� �— — Date <br /> Charces: Renta! �� Custod al <br /> Cooks _ Other charges: <br /> Note: <br />