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Golden Gardens Park In -Water Dog Training Permit Application <br />1. Applicant Information: <br />Name: j M in (� Phone: � � W � 1 I V Q �y �J <br />Address: 'r II V n 1` �] k City /Zip:Q <br />E -Mail Address: fJ �7lJW l"iQf`{I( +�� ✓ 1 <br />2. Animal Information <br />(Include all dogs to be engaged in in -water training at Golden Gardens Park, list additional dogs on <br />reverse side): <br />a) Dog #1 <br />Breed <br />o <br />Color <br />ItAla <br />Age <br />Rabies vaccination date <br />- 0 <br />Rabies expiration date <br />Dog License Number <br />b) Dog #2 <br />Breed <br />Color <br />Age <br />Rabies vaccination date <br />Rabies expiration date <br />Dog License Number <br />3. Signature <br />w <br />I certify that the information I am providing herein is true to the best of my knowledge. i have <br />received a copy of Administrative Order No. 58- 13 -07, and the Eugene Park and Open Space Rules, <br />and I agree to comply with all applicable regulations. I understand that any violation of any <br />provision of the Administrative Order may result in the City revoking the permit and may be a basis <br />for the City to deny a future permit application. I agree to indemnify, defend, and hold harmless the <br />City of Eugene, its officials, agents and employee from and against any and all claims of injuryto <br />property or persons that may arise as a result of in -water dog training activities for which I seek <br />this permit. I agree to pay all costs of any damage and /or vandalism to the park or facilities used in <br />relation W is 6rmit. <br />Signat re Date Print Name <br />{00090457;1} Golden Gardens Park - In -Water Dog Training Permit Application Page 1 <br />