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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. •_ 4 <br /> Name <br /> :l:t ,i(u! �'%cX•{ Home Phone Bus. Phone <br /> t <br /> Addresses '0; % Y,�'• �� �� �. ,<.`� Today's Dae j <br /> 11 _ , <br /> Name of Group or Organization`.• '� <br /> Intended Use 1 r <br /> r- <br /> Date(s) wanted --<<� y r1f y'J Day(s) Su M::TAW Th F Sa (circle) <br /> Building: <br /> High School - Auditorium <br /> Community Center Cafeteria <br /> -_ - Wilshire Park Etem:Scho9l-_=__- .- _. _-_.---- _-- Classroom(s) <br /> _-yOther/-_1 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 `���%� pm - Admission: Free Charge <br /> Activity ends am )pm - Will merchandise be sold? <br /> • <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. <br /> (signature of responsible person) <br /> Bill to: <br /> (name) (address) <br />---------------------------------------------FOR OFFICE USE ONLY------------------------------------------------- <br /> Class Ins Approved by _7*i `-►; t• Date <br /> Charges: Rental Custodial <br /> Cooks Other charges: <br /> r <br /> Note: �' ,. .C_ ice'. r_ !� ;[ : , -. f/•... <br /> ......-- - ._ _ .___w.-__w_-.. n•u•e� -.._.____�__w_-.. nu•r n.._•-��-w�- nAn_♦-v4�Y�Pwwr <br />