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INDEPENDENT SCHOOL DISTRICT NO. 282 <br /> Community services Department <br /> 3301 Silver Lake Rd 0 St. Anthony, MN 55418 9 Phone: 761-5021 <br /> Facilities Reservation Form Permit No. <br /> Name Horne Phone Bus. Phone- <br /> • <br /> Address-- <br /> Date <br /> -z <br /> Name of-Group or Organization.. _47. eo,114 <br /> Intended Use <br /> or <br /> Date(s) wanted <br /> ed 76t Itc' r W Th F <a c <br /> Day(s) Su M ircle) <br /> Building*.--'. <br /> —High School —Auditorium <br /> —Park View Community Center —Cafeteria <br /> Wilshire,Park Ele Spbool Classroom(s) # <br /> Other —Gymnasium (If High School, circle one: <br /> OLD NEW <br /> Kitchenp X, <br /> Other er <br /> Doors to open. —am —prn Expected attendance: <br /> Activity.1b6gi'his'_arry4LL?–)pM Admission: —Free Charge <br /> Activity ends am <br /> —aml?�/_ -prn Will merchandise be sold? <br /> Special arrangements needed (chairs, cooks. AV equipment, etc.): • <br /> I <br /> hereby certify that I am an dgent of the abovd 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 Sdhool, <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 /> f <br /> (signature of responsible?ers6A) <br /> Bill to: <br /> (name) (address) <br />---------------------- -------------------FOR Fy F(CE USE OK ---------------------- —--------- <br /> Approved by <br /> Class Ins Date <br /> Charges: Rental Custodial <br /> Cooks Other charges: <br /> ` / / • <br /> Note:%CCj-diu <br /> -7 <br /> e4i y< <br /> GOLD—ApPUCAnIrs Copy <br /> WHIM—community Swvkes OMCS Copy CANARY—SuWness OMO COPY PINK—Custodbns COPY <br />