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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 ro C9— Home Phone of I-,q- Bus. Phone <br /> Address 2E, J; 2�3110/L 4,,X01 Today's Date <br /> Name of Group or Organization <br /> Intended Use / �^ �y I1GG.; a/✓ <br /> Date(s) wanted Day(s) Su M T W Th F Sa (circle) <br /> Building: <br /> High School Auditorium <br /> Community Center Cafeteria <br /> Wilshire�p,ark Elem. School Classroom(s) <br /> �fJther Try yf7/n ry Gymnasium (If High School, circle one: <br /> LARGE SMALL ) <br /> Kitchen <br /> Other <br /> Doors to open am pm Expected attendance: 7 C <br /> Activity begins am L�9 Admission: Free 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, 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. y <br /> L /Cr�Gccc� G� <br /> (signature of responsible person) <br /> Bill to: <br /> (name) (address) <br />----------------------------------------------FOR ICE USE ONLY--------------------------____--- ��---- <br /> Class Ins Approve b ,, Date <br /> Charges: Rental Custodial <br /> C oks Other charges: <br /> Note: <br /> gums -L—d,—CM—Cm CANARY—Sunln�Office Coos PINK—Cwfearn Cosy GOLD—Aodleenh COM 4 <br />