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INDEPENDENT SCHOOL DISTRICT NO. 282 <br /> r) Community Services Department <br /> 3301 Silver Lake Rd • St. Anthony, MN 55418 • Phone: 781-5021 , <br /> Facilities Reservation Form Permit N(�,4 <br /> Name Home-Phort °f��� Bus. Phone <br /> Address Today's Date <br /> Name of Group or Or nization <br /> Intended Use <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 Park Elem. School Classroom(s) # <br /> Other -Gymnasium (If High School, circle one: <br /> LARGE SMALL ) <br /> Kitchen <br /> Other <br /> Doors to open am�Gl p Expected attendance: v <br /> Activity begins am pm Admission: Free Charge <br /> Activity ends amm Will merchandise be sold? <br /> Special arrangements needed (chairs, cooks, AV equipment, etc.): �_� Vit.. • <br /> I hereby certify that I am an agent othabove 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 facjlity.Rentee waives all rights and claims for <br /> potential damages incurred in this rental arrangement. <br /> ,.>b"' <br /> (signature of responsiblefperson) <br /> Bill to: <br /> (name) (address) <br /> FO RO FI CE USE ONLY--- P'------------------------ - ------- <br /> 1_2 S, A <br /> Class Ins Approved by �i • �'� f tr . Date <br /> Charges: Rental Custodial <br /> Cooks Other charges:- <br /> Note-,L4 Z4 <br /> -r • <br /> WHITE—Community services Office Copy CANARY—Business OHks Copy PINK—Cudodions Copy COLD—Applkant's Copy <br />