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Golden Gardens Park In -Water Dog Training Permit Application <br />1. Applicant Information: <br />Name � 4 7 e, -_ n Phone: 3� L f/ I I V <br />�+ <br />Address: 910 1,' � tal r City /Zip: -jLl;gc g7qyf / � <br />E -Mail Address: 10r6?e'1';C hJV_ eq 6 cid) <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 />iz Yei i;� Ite . r /t'v' d <br />Color <br />p <br />Age <br />2 , r ,-4 , S 1V-I-'/22 <br />Rabies vaccination date <br />3 <br />Rabies expiration date <br />Dog License Number <br />J3 7 <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 />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 injury to <br />property or persons that may arise as a result of in -water dog training activities for which I seek <br />this per i I agree to pay all costs of any damage and /or vandalism to the park or facilities used in <br />Lk qw_ <br />relat�o �€ thi rmit <br />Signature ee Date Print Name <br />{00090457;11 Golden Gardens Park - In -Water Aog Training Permit Application Page 1 <br />