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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 l <br /> Facilities Reservation Form Permit No. <br /> Name / - `� Home Phone us. Phone <br /> Address _ Date <br /> Name of Group or Organization _ w" <br /> Intended Use <br /> r <br /> Date(s) wanted '� Day(s) Su M T W Th F Sa (circle) <br /> Building: <br /> High School Auditorium <br /> Park View Community Center Cafeteria <br /> Wilshire Park Elem. School Classrooms) # <br /> Other Gymnasium (If High School, circle one: <br /> OLD NEW ) <br /> Kitchen <br /> Other <br /> Doors to open am pm Expected attendance: <br /> Activity begins am m Admission: Free Charge <br /> Activity ends am 'L?;eP)m Will merchandise be sold? <br /> Special arrangements needed (chairs, cooks, AV equipment, etc.): <br /> I her 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,l 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 />-..---------------------------------------------FOR OFFICE USE ONLY------------------------------------------------ <br /> Class Ins Approved by Date <br /> Charges: Rental Custodial <br /> Cooks Other charges: <br /> Note: <br /> WHITE—CormnurJly Sorvk*e OMerr COPY CANARY—Sudnees 01tkO COPY PINK—CusloAla s COP/ COLD—Appl"nl's Copy <br />