Equine Surrender Form

Equine Surrender Form

Name: ______Date: ______

Address: ______Email: ______

City, State and Zip: ______Phone # ______

Driver’s License # ______State______

Equine’s Name, Registration, or Brand:______

Breed: ______Age: ______Sex:____

How long have you owned this equine? ______

Equine’s Previous Use: ______

Has this equine had any type of surgery? ____ Yes ____ No ____ Unknown

If you answered yes, please list the type of surgery. ______

Does this horse have any lameness issues? ? ____ Yes ____ No ____ Unknown

If you answered yes, please describe. ______

Current Vet: ______Phone: ______

Current Ferrier: ______Phone: ______

If equine is a mare, is there a possibility she could be pregnant?____ Yes ____ No ____

Please describe the equine’s riding history.

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Please describe the equine’s temperament, soundness and any habits about which Honey Do Animal Rescue, Inc.and its adopters should know.

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Does this equine’s temperament, soundness or habits pose any danger to those riding or

handling it (e.g. bites, kicks, rears, bucks shies at vehicles, will not trailer without

tranquilizer, etc.)? ____ Yes ____ No ____ Unknown

Has this equine ever injured anyone? ____ Yes ____ No ____ Unknown

If you answered yes to either of the two previous questions, please explain in full detail

(attach additional sheet if necessary.)

Is this equine a cribber? ____ Yes ____ No ____ Unknown

Please list dates of equine’s last vaccinations, worming, hoof and dental care.

Coggins __ Neg. ___ Pos.Date______Unknown

E & W Encephalomyelitis Date______Unknown

Tetanus Date______Unknown

Rhino-Flu Date______Unknown

Rabies Date______Unknown

West NileDate______Unknown

Botulism Date______Unknown

Worming

Product: ______Date______Unknown

Hoof Care Date______Unknown

Dental Care Date______Unknown

To the best of my knowledge, the above information about the equine’s riding history, temperament, and medical treatment is true and correct.

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Owner’s signature Date

Surrender Donation:

Will you be making a tax deductible donation to help cover the costs of caring for this

equine while it is at Honey Do Animal Rescue, Inc.? ______Yes ______No. If yes, the tax deductible donation is in the amount of $ ______.

Acknowledgement:

Having sole ownership of the above equine, I/we hereby surrender the equine ______, registration/brand: ______to Honey Do Animal Rescue, Inc. and thereby relinquish all ownership in this animal.

I understand that Honey Do Animal Rescue, Inc. will not be responsible for any financial obligations incurred by me on behalf of this equine prior to its surrender to Honey Do Animal Rescue, Inc.

Should Honey Do Animal Rescue, Inc.find a suitable home for this equine, I understand that I am consenting to the adoption of the equine by an individual/organizationapproved by Honey Do Animal Rescue, Inc.

I understand and agree that I amtransferring full legal ownership of my equine to Honey Do Animal Rescue, Inc.and Honey Do Animal Rescue, Inc. has full authority for all necessary veterinarianprocedures including euthanasia.

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OwnerSignature Printed Name Date

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OwnerSignature Printed Name Date

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OwnerSignature Printed Name Date

H.D.A.R Use Only:

Accepted by: ______. Comments: ______

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