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^ INDEPENDENT SCHOO-.DISTRICT NO. 282 <br /> Community Servicei Department <br /> .3301 Silver Lake Rd • St. Anthony, MN 55418 • Phone: 781-5021 <br /> br <br /> ' Facilities Reservation Form Permit No. <br /> Name ' Home Phone 7 j-�- Bus. Phone4V L) • <br /> . I <br /> ~ Today's 7 Jf <br /> Address J y's Date <br /> Cj <br /> Name of Group or Organization <br /> r <br /> Intended Use _ <br /> Date(s) wanted Day(s) 4QM T W Th F Sa (circle) <br /> Building: <br /> High School Auditorium <br /> Community Cent Cafeteria <br /> Wilshire Pad_ Z6r6,School Classrooms) # <br /> Other -Gymnasium (If High School, circle one: <br /> LARGE SMALL ) <br /> Kitchen <br /> Other <br /> Doors to open am pm Expected attendance: <br /> Activity begins am _t6l-pm Admission: Free Charge <br /> Activity ends ami pm Will merchandise be sold. n't? <br /> Special arrangements needed (chairs, cooks• V 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 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 /> ---------------------------------------------FOAOFF.ICE USE ONLY;----------------------- <br /> Class Ins Af----__ --_------------ <br /> roved b' /`��it�t _1 1 �'�i L� �{ <br /> PP Y / Date <br /> i <br /> /,`/` <br /> Charges: <br /> . Rental .--- , ,.". ♦ ^ --.._ Custodial-.Y` <br /> Cooks = Other charges: - ' <br /> Note: <br /> _.:_...c wmrm_co wmft servk+s oMlee copy'_CANARY:—suMn.4 <br /> Oft*Cepy PINK—Cwlodw Coev OOLO—Aod1un19 Gear <br />