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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. 362/ �o <br /> fkame �' :Ro__r� Home Phone /��""� Bus. Phone 6.157— <br /> A d d r e s s <br /> I 7`Address 3 /`�� •t-/f✓ 4, Ate- Today's Date J&C, - 2 g7 <br /> Name of Group or Organization <br /> Intended Use °G • 'uC, <br /> Date(s) wanted ���_ ZZ Day(s) Su M T W ThQSa (circle) <br /> Building: <br /> High School Auditorium <br /> Community Center Cafeteria <br /> Wilshire Park Elem. School Classroom(s) X <br /> Other Gymnasium (If High School, circle one: <br /> Q LARGE SMALL ) <br /> Kitchen C ! <br /> Other <br /> Doors to open am pm Expected attendance: 160 — ZO <br /> Activity begins —am_3'0�m Admission: free Charge <br /> Activity ends am J_ 1 Will merchandise be sold? ^10 <br /> Opecial 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 forgiving <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 f i " y. Rente ives all rights and claims for <br /> potential damages incurred in this rental arrangement. <br /> (sign t e of responsible person) <br /> Bill to: <br /> (name) (address) <br /> ---------------------------------------------- O ICE USE ONLY--- <br /> - <br /> -------------------- -------- <br /> Class Ins Approved � "6__1r1;4W <br /> Charges: Rental Custodial <br /> Cooks Other charges: <br /> O <br /> WNrrE—C mmwdfy Services OHIce Copy CANARY—5"ne"ONIw Copy PINK—QnloBrr copy OOLO—Applkrnri COPY <br />