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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 TO/7f ��Ioe Phone�,3G-4 3/4 I/ Bus. Phone 1,�� -►��Sylo <br /> Address i/%off ! /'� S ` .r/�rJ 3,Z fl Tod 4 e c 4 . 1 <br /> Y <br /> Name of Group or Organization <br /> Intended Use /7 <br /> Date(s) wanted f Day(s) Su M T W©F Sa (circle) <br /> Building: <br /> High School Auditorium <br /> Community Center Cafeteria <br /> Wilshire Park Elem. S hpol , Classroom(s) # <br /> X—Other f Ile Gymnasium (if High School, circle one: <br /> ' LARGE SMALL.) <br /> - Kitchen <br /> Other <br /> Doors to open amhh pm Expected attendance: <br /> Activity begins am , V 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 1 will be solely responsible fogy 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 /> (signatu a of responsible person) <br /> Bill to: <br /> (name) (address) <br /> ----------------------------------------------F OFFICE USE ONY-------------------------__ <br /> Class Inn ' Approved b r Date <br /> Charges: Renta' i1 AA Custodial <br /> Cooks nth r charges: • <br /> Note: <br /> v�p <br /> WHITE—Community services Office Copy CANARY—Business Oftke Copy PINK—Custodians Copy GOLD—Applkanrs Copy <br />