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I�VDEPEND4 VSCHOCL-DISTRICT-N <br /> 41 <br /> .C►oRlnlun�ty`5 �rlcea Department <br /> Slltrer7 L a a°Rd :Sid '�tholf ; MN '55418 • PhQ�te'" 0 <br /> �,. <br /> Facllltlor,neaervatlivaon Form`� mitTN.Mo�.� <br /> F� .1Sy s.u,.,.A.el.flya kyr 4 -_ -..4 ♦M'i R/�iY� 1 i{l wzl.A4 <br /> R <br /> Home Ptione B ^t1� - <br /> ' 4;y �•,7ty°�3' ^"' i .fi lYnU 'Cf A .Fy _ .. _ ktE �y.s.�,,,,y�a° "ta` " .- 'M�rti <br /> Address: t " Today's Date. ` ' <br /> Name"',of'Grotip or Organization ti <br /> Intended Use <br /> Dates) wanted ! ��/ Day(s) SU M T W, Tti F (circle) <br /> Building:. ;.,.�. . <br /> High School Auditorium: °`• <br /> Community Center Cafeteria <br /> Wilshire Park Elea. School Classroom(s) # ; <br /> Other Gymnasium (If High School, circle one: <br /> a, <br /> LARGE. SMALL ) <br /> f <br /> Kitchen <br /> Other <br /> Doors to open am pm Expected attendance: <br /> Activity begins _am :wpm Admission: Free Charge <br /> Activity ends am ~rpm 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, 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,gentee 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 /> .harges: Rental ' Custodial <br /> Cooks Other charges: <br /> Note: <br /> WHITE—r nmueltv Sanies Office Ce v -C 4MARV—Rudc.ene nPor<r.— r•rllr n Aa.,u­�V.[•r.•r ' <br />