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i <br /> INDEPENDENT SCHOOL DISTRICT NO. 282 <br /> Community Services Department <br /> 3301 Silver Lake Rd • St. Anthony, MN 55418 • Phone: 781-5021 <br /> Fagilities Reservation Form Permit No <br /> Name ` —Q�'��� Home Phone Bus. Phone <br /> Address y o / �� x �+ Today's Date <br /> I s <br /> Name of Group or Organization <br /> Intended Use <br /> Date(s) wanted 0 Day(s Su M T W Th F Sa (circle) <br /> Building: <br /> High School Auditorium <br /> Community Center Cafeteria <br /> Wilshire Park Elem. School Classroom(s) # <br /> Other f 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 /> 1 hereby certify that 1 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 i :� Date 71 L I N-S <br /> - r <br /> Charges: Rental Custodial <br /> Cooks Other charges: <br /> Note: /�� _ �_. -+✓ - h <br /> n.K"r- CAMU1Y_M...nm-r- Dimer—r...L..f....rano eeLn_Inalkmrs Ceer <br />