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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 -�`�'`'��f'� . ` -� -�� - Home Phone 114d �y� Bus' Phone <br /> Address C"�� r7"� ifi7�'�-✓L r> Date r' / <br /> Name of Group or Organization �'� � ' -"-� ZZa <br /> Intended Use <br /> Date(s) wanted y L Day(s) Su M T W ST F Sa (circle) <br /> Building: <br /> High School Auditorium <br /> Park View Community Center Cafeteria <br /> Wilshire ark El m. 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 CPm Admission: Charge <br /> Activity ends am �/ � pm 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,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 /> Or <br /> ` (signature of responsible person) <br /> Bill to: <br /> (name) (address) <br /> ----------------------------------------------FOR OFFICE USE QNLY-----------------------------------------------• <br /> Class Ins Approved by ', -%'---"L 1 Date <br /> Charges: Rental L Custodial <br /> Cooks Other charges: <br /> Note: <br /> WHIT[—ComMuMly feRACN OrRCS Copy CANARY—SudnnM 01 Copy PINK—CuNoaw Copy GOLD—APPReoM's COPY <br />