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INDEPENDENT SCHOOL DISTRICT NO. 282 <br /> Community Services Department <br /> 3301 Silver Lake Rd a St. Anthony, MN 55418 • Phone: 781-5021 r.. <br /> Facili les Reservation Form Permit No. <br /> Name Home Phone Allc Phone <br /> Address ��`' Today' to � <br /> Name of Group or.Organization <br /> Intended Use <br /> Date(s) wanted / 7-,62 Day(s) Su M T W Th F Sa (circle) <br /> Building: <br /> High School Auditorium <br /> Community Center Cafeteria <br /> Wilshire Park Elem. Schogl Classroom(s) # <br /> Other Gymnasium (If High School, circle one: <br /> LARGE SMALL ) <br /> Kitchen <br /> Other <br /> Doors to open am pm Expected attendance: <br /> e" <br /> Activity begins am pm 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. <br /> - le.�� _- >.;;-'...ter,•. <br /> (signature of responsible person) <br /> Bill to: <br /> (name) (address) <br />---------------------------------------------FOR OFFICE USE ONLY--------------------------- -- ----- --------- <br /> f <br /> Class Ins Approved by. ,i ��.<i. .. l } /f� lCe'f..c_Date <br /> Charges: Rental Custodial <br /> Cooks Other charg :h • <br /> Note: _/V4 i� / �1f <br /> WNITE—Community.-Services Office Copy CANARY—Business OHIu Copy PINK—Custodlun Copy GOLD—Applkanre Copy <br />