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r <br /> INDEPENDENT SCHOOL DISTRICT NO. 282 <br /> Community Services Department <br /> 3301 Silver Lake Rd • St. Anthony, MN 55418 • Phone: 706-1166 <br /> Facilities Reservation Form Permit No. <br /> Name *'i/� Home Phone Bus. Phone <br /> Address Today's Date <br /> �r <br /> r <br /> Name'of Group or Organization <br /> Intended Use <br /> Date(s) wanted Day(s) SuO W _F Sa (circle) <br /> r <br /> Building: <br /> High School Auditorium <br /> Community Center Cafeteria <br /> Wilshire Park,Elem. School Classroom(s) # <br /> _Other r`'� `! -� Gymnasium (If High School, circle one: <br /> LARGE SMALL ) <br /> Kitchen <br /> Other <br /> Doors to open am pm Expected attendance: % <br /> Activity begins '—' ani pm Admission: Free Charge <br /> Activity ends am pm Will merchandise be sold? <br /> Special arrangements needed (chairs, cooks, AV equipment, etc.): <br /> r <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 arrange ent, rentee agrees to hold harmless <br /> I.S.D. 282 and its representatives from all claims incurred in use of the facility. ntee waives all rights and claims for <br /> potential damages incurred in this rental arrangement. �_.j °,• <br /> responsible person) <br /> Bill to: <br /> (name) (address) <br />------------------------------- ---------------FOR OFFICE USE ONLY <br /> ------------------------------------------------- <br /> Class Ins Approved by ��'' �t ^-~�-} �f r t 'r tL,L Date <br /> Charges: Rental Custodial <br /> Cooks Other charges: <br /> Note: <br /> WNITC—r,..,....-u„r. L—efn—raev CANARY—Business OHlee Coov PINK—Custodians Coot GOLD—ADolloanra Copy <br />