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INDEPENDENT S.CHOOL`DISTRICT. NO. 282 <br /> .• . <br /> Community Services Department <br /> 3301 Silver Lake Rd • St..Anthony, MN 55418..• Phone:'781-5021 <br /> ,7PT Facilities Reservation Form permit No. <br /> Name' =T, ":'f ..� �.G. f' 1r ;. -�(4f <br /> :. . <br /> Home Phone Bus. Phone/ <br /> Addressf .. GL>` �(. Today's Date <br /> Name.of"Group or Organization <br /> Intended Use <br /> �d <br /> Date(s) wanted (,%` �i ( - + t` f.��;4' �'f" Day(s) Su M T W Tt(F Sa (circle) <br /> Building: <br /> High School Auditorium . <br /> Community Center Cafeteria <br /> Wilshire Park Elem. School �, 1-- Classroom(s) # <br /> Other '� : `= o. � Gymnasium (If High School, circle one: <br /> / LARGE SMALL ) <br /> Kitchen <br /> t <br /> Other <br /> Doors to open /a I pm Expected attendance:klActivity begins mpm / Admission: Free Charge <br /> Activit `Y endsr 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 /> (signature of r s onsible person) <br /> Bill to: <br /> (name). (address) <br /> f <br />---------------------------------------------F QB OFICE USE ONLY-------------------- <br /> --- r --------- <br /> Class Ins Approved y' ' <br /> f � jai C <br /> Charges: Rental Custodial • <br /> Cooks Other charges: <br /> Note: <br /> WHITE—Community Services omce Copy CANARY—Business Office Copy PINK—Custodians Copy GOLD—AppllesnPa Copy <br />