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-NO. 282 <br /> INDEPENDENT SCHOOL DISTRICT <br /> Community Services Department <br /> 3301 Silver Lake Rd • St. Anthony, MN 55418 a Phone: 781-5021 <br /> Facilities Reservation Form Permit No. <br /> Name �� �Y�' fJIJI�� Home Phone � ' Z Bus. Phone-11911. <br /> k <br /> Address ►vim- IL. E� Today's-Date fQ" � <br /> Name of Group or Or anization �' I {� ►�. �' J k. <br /> Intended Use ,611111_ � �-✓� `'� <br /> Date(s) wanted <br /> Day(s) T W Th F Sa (circle) <br /> Building: <br /> High School Auditorium <br /> Community Center Cafeteria <br /> Wilshire _Park'Elem..School f Classro.om(s):# <br /> -Other '' ''' _` .- � Gymnasium�_(If'High School, circle one: <br /> LARGE SMALL ) <br /> Kitchen ; <br /> Other <br /> Doors to open m pm' Expected attendance. <br /> Activity begins am ' pm Admission:­. Free Charge <br /> Activity ends am a pm Will merchandise be sold? <br /> Special arrangements needed (chairs, cooks, AV equipment, etc.): ! '%� - . �. ► 1 <br /> J-1 <br /> i <br /> i <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,l will attend this function,and I will be solely responsible forgiving <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. ��nn <br /> (signature of responsible person) <br /> Bill to: <br /> (name) (address) <br /> ---------------------------------------------FOR O FICE USE ONLY----------------------------------------------- <br /> Class Ins Approved b t ' �.%!r .( A / <br /> PP Y� Date__1f <br /> Charges: Rental Custodial <br /> Cooks Othe charges: • <br /> Note: �/�{ ) J1 F > <br /> - , ;� ! <br /> WHITE—Community Services Office Copy CANARY—Business Office Copy PINK—Custodians Copy GOLD—Appllcanre Copy <br />