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Bark Park Waiver and Membership Application

I acknowledge that this application hereby represents and warrants that my dogs are licensed and are current with the required vaccinations and that the information is true and accurate for the dogs identified below.

I understand that I am solely responsible for supervising my dogs and determining whether this is a suitable activity for them. Due to the unpredictability of animal nature, I further acknowledge the risks and hazards that may arise from such interaction and understand that I am participating in this activity at my own risk (and risk of my dogs). I voluntarily agree to assume full risk and legal liability to which I waive, relinquish, release and forever discharge That Dane Bar, its employees and affiliates from all claims for any injuries, damages or loss, regardless of severity that I may sustain as result of participating in any and all activities associated with the use and attendance of this facility.

I acknowledge that That Dane Bar cannot guarantee that all dogs in the facility are vaccinated nor the predictability of behavior and temperament.

I understand that I am responsible for acquiring, reviewing and understanding all rules, regulations and policies prior to partaking in the services offered. That Dane Bar reserves the right to refuse service or use of its facilities to any owner and/or dog who acts aggressively, disruptive or otherwise pose a danger to themselves or other guests (human and canine).

I understand That Dane Bar may use my pets name, and/or any image or video media obtained on our premise for promotional material, including but not limited to social media, website substance, advertising, printed media, video media, press and so forth.

I Agree

Today's Date: November 22, 2019

First Human's Name

First Name*

Last Name*

Phone*
First Human's Date of Birth*
I certify that I am 21 years of age or older
First Human's Information

Veterinarian:

Veterinarian Phone:

DOG'S INFORMATION


Dog's Name: *

Breed: *
Gender:*
Spay/Neutered?*
No
Yes
I certify that my dog is up to date on all required vaccinations including his/her Rabies, Bordetella and DHPP and all shots will remain up to date per the Bark Park requirement. *
I agree.

ADDITIONAL DOG INFORMATION


Dog's Name:

Breed:
Gender:
Spayed/Neutered?*
No
Yes
I certify that my dog is up to date on all required vaccinations including his/her Rabies, Bordetella and DHPP and all shots will remain up to date per the Bark Park requirement.
I agree.
First Human's Signature*
Second Human's Name

First Name*

Last Name*
Second Human's Date of Birth*
Second Human's Information

Veterinarian:

Veterinarian Phone:

DOG'S INFORMATION


Dog's Name: *

Breed: *
Gender:*
Spay/Neutered?*
No
Yes
I certify that my dog is up to date on all required vaccinations including his/her Rabies, Bordetella and DHPP and all shots will remain up to date per the Bark Park requirement. *
I agree.

ADDITIONAL DOG INFORMATION


Dog's Name:

Breed:
Gender:
Spayed/Neutered?*
No
Yes
I certify that my dog is up to date on all required vaccinations including his/her Rabies, Bordetella and DHPP and all shots will remain up to date per the Bark Park requirement.
I agree.
Third Human's Name

First Name*

Last Name*
Third Human's Date of Birth*
Third Human's Information

Veterinarian:

Veterinarian Phone:

DOG'S INFORMATION


Dog's Name: *

Breed: *
Gender:*
Spay/Neutered?*
No
Yes
I certify that my dog is up to date on all required vaccinations including his/her Rabies, Bordetella and DHPP and all shots will remain up to date per the Bark Park requirement. *
I agree.

ADDITIONAL DOG INFORMATION


Dog's Name:

Breed:
Gender:
Spayed/Neutered?*
No
Yes
I certify that my dog is up to date on all required vaccinations including his/her Rabies, Bordetella and DHPP and all shots will remain up to date per the Bark Park requirement.
I agree.
Fourth Human's Name

First Name*

Last Name*
Fourth Human's Date of Birth*
Fourth Human's Information

Veterinarian:

Veterinarian Phone:

DOG'S INFORMATION


Dog's Name: *

Breed: *
Gender:*
Spay/Neutered?*
No
Yes
I certify that my dog is up to date on all required vaccinations including his/her Rabies, Bordetella and DHPP and all shots will remain up to date per the Bark Park requirement. *
I agree.

ADDITIONAL DOG INFORMATION


Dog's Name:

Breed:
Gender:
Spayed/Neutered?*
No
Yes
I certify that my dog is up to date on all required vaccinations including his/her Rabies, Bordetella and DHPP and all shots will remain up to date per the Bark Park requirement.
I agree.
Fifth Human's Name

First Name*

Last Name*
Fifth Human's Date of Birth*
Fifth Human's Information

Veterinarian:

Veterinarian Phone:

DOG'S INFORMATION


Dog's Name: *

Breed: *
Gender:*
Spay/Neutered?*
No
Yes
I certify that my dog is up to date on all required vaccinations including his/her Rabies, Bordetella and DHPP and all shots will remain up to date per the Bark Park requirement. *
I agree.

ADDITIONAL DOG INFORMATION


Dog's Name:

Breed:
Gender:
Spayed/Neutered?*
No
Yes
I certify that my dog is up to date on all required vaccinations including his/her Rabies, Bordetella and DHPP and all shots will remain up to date per the Bark Park requirement.
I agree.
Sixth Human's Name

First Name*

Last Name*
Sixth Human's Date of Birth*
Sixth Human's Information

Veterinarian:

Veterinarian Phone:

DOG'S INFORMATION


Dog's Name: *

Breed: *
Gender:*
Spay/Neutered?*
No
Yes
I certify that my dog is up to date on all required vaccinations including his/her Rabies, Bordetella and DHPP and all shots will remain up to date per the Bark Park requirement. *
I agree.

ADDITIONAL DOG INFORMATION


Dog's Name:

Breed:
Gender:
Spayed/Neutered?*
No
Yes
I certify that my dog is up to date on all required vaccinations including his/her Rabies, Bordetella and DHPP and all shots will remain up to date per the Bark Park requirement.
I agree.
Seventh Human's Name

First Name*

Last Name*
Seventh Human's Date of Birth*
Seventh Human's Information

Veterinarian:

Veterinarian Phone:

DOG'S INFORMATION


Dog's Name: *

Breed: *
Gender:*
Spay/Neutered?*
No
Yes
I certify that my dog is up to date on all required vaccinations including his/her Rabies, Bordetella and DHPP and all shots will remain up to date per the Bark Park requirement. *
I agree.

ADDITIONAL DOG INFORMATION


Dog's Name:

Breed:
Gender:
Spayed/Neutered?*
No
Yes
I certify that my dog is up to date on all required vaccinations including his/her Rabies, Bordetella and DHPP and all shots will remain up to date per the Bark Park requirement.
I agree.
Eighth Human's Name

First Name*

Last Name*
Eighth Human's Date of Birth*
Eighth Human's Information

Veterinarian:

Veterinarian Phone:

DOG'S INFORMATION


Dog's Name: *

Breed: *
Gender:*
Spay/Neutered?*
No
Yes
I certify that my dog is up to date on all required vaccinations including his/her Rabies, Bordetella and DHPP and all shots will remain up to date per the Bark Park requirement. *
I agree.

ADDITIONAL DOG INFORMATION


Dog's Name:

Breed:
Gender:
Spayed/Neutered?*
No
Yes
I certify that my dog is up to date on all required vaccinations including his/her Rabies, Bordetella and DHPP and all shots will remain up to date per the Bark Park requirement.
I agree.
Ninth Human's Name

First Name*

Last Name*
Ninth Human's Date of Birth*
Ninth Human's Information

Veterinarian:

Veterinarian Phone:

DOG'S INFORMATION


Dog's Name: *

Breed: *
Gender:*
Spay/Neutered?*
No
Yes
I certify that my dog is up to date on all required vaccinations including his/her Rabies, Bordetella and DHPP and all shots will remain up to date per the Bark Park requirement. *
I agree.

ADDITIONAL DOG INFORMATION


Dog's Name:

Breed:
Gender:
Spayed/Neutered?*
No
Yes
I certify that my dog is up to date on all required vaccinations including his/her Rabies, Bordetella and DHPP and all shots will remain up to date per the Bark Park requirement.
I agree.
Tenth Human's Name

First Name*

Last Name*
Tenth Human's Date of Birth*
Tenth Human's Information

Veterinarian:

Veterinarian Phone:

DOG'S INFORMATION


Dog's Name: *

Breed: *
Gender:*
Spay/Neutered?*
No
Yes
I certify that my dog is up to date on all required vaccinations including his/her Rabies, Bordetella and DHPP and all shots will remain up to date per the Bark Park requirement. *
I agree.

ADDITIONAL DOG INFORMATION


Dog's Name:

Breed:
Gender:
Spayed/Neutered?*
No
Yes
I certify that my dog is up to date on all required vaccinations including his/her Rabies, Bordetella and DHPP and all shots will remain up to date per the Bark Park requirement.
I agree.
Human's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email
Check to receive information, news, and discounts by e-mail.
A signed copy of this waiver will be sent to the email address you provide.
Pass or Membership Plan
AUTO-PAY AUTHORIZATION AND CANCELLATION POLICY

I hereby authorize That Dane Lady, LLC (DBA That Dane Bar) to maintain my credit card number on file and charge purchases made and/or reoccurring services against the card at the prices in effect at the time of the transaction. All charges will be final when made. Should it occur that you wish to cancel your membership plan, please do so as soon as possible before the next reoccurring payment is due.

By signing below, I acknowledge that I have read and fully understand the terms of the above Authorization, Agreement and Waiver terms and conditions contained herein.


Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Phone*
Parent or Guardian's Date of Birth*
I certify that I am 21 years of age or older
Parent or Guardian's Information

Veterinarian:

Veterinarian Phone:

DOG'S INFORMATION


Dog's Name: *

Breed: *
Gender:*
Spay/Neutered?*
No
Yes
I certify that my dog is up to date on all required vaccinations including his/her Rabies, Bordetella and DHPP and all shots will remain up to date per the Bark Park requirement. *
I agree.

ADDITIONAL DOG INFORMATION


Dog's Name:

Breed:
Gender:
Spayed/Neutered?*
No
Yes
I certify that my dog is up to date on all required vaccinations including his/her Rabies, Bordetella and DHPP and all shots will remain up to date per the Bark Park requirement.
I agree.
Parent or Guardian's Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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