Equine Salvation

4019 Bucyrus-Iberia Rd.

Caledonia, OH 43314
www.equinesalvation.org

Surrender Agreement
Horse Information
Horses Nickname______________________________________________
Horses Full Registered Name__________________________________________________________
Registration Association and #_____________________________________
(original breed transfer w/ signed transfer papers must be submitted with this form)

Breed____________________________________
Age_____________________________________
Gender___________________________________
Color_____________________________________
Descriptive Markings and Brands:____________________________________________________
________________________________________________________________________________
________________________________________________________________________________
Current Owner Information
Current Owner__________________________________________
Address_______________________________________________
City, State, Zip__________________________________________
Phone_________________________________________________
E-mail Address__________________________________________
How long has this horse been with the current owner?____________________________________
Reason for surrendering this horse to Equine Salvation? __________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
(We do NOT judge people based on their reasons for surrendering their equines)

Medical and Temperament History

Most recent vaccinations including date administered:______________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
Most recent de-worming including date administered and product used:________________________
Does this horse have a current negative Coggins test?

Yes

No

(If so original Coggins test must accompany this form)

Known unsoundness, lameness or other medical conditions:_________________________________

________________________________________________________________________________
________________________________________________________________________________
Any know feed or medication allergies?_________________________________________________
Does this horse stand tied?
Yes
Does this horse load into a trailer?
Yes
Does this horse lead?
Yes
Does this horse clip?
Yes
Does this horse stand to be groomed? Yes
Does this horse stand to be bathed?
Yes
Does this horse stand for the farrier?
Yes
Does this horse stand to be de-wormed?
Does this horse stand to be vaccinated?
Is this horse broke to ride?

Yes

No
No
No
No
No
No
No
Yes
Yes

No
No
No

(If Yes, please explain the level of training & the situations in which this horse has been ridden)

________________________________________________________________________________
________________________________________________________________________________
Please list all special needs, likes/dislikes, quirks, vices or any other necessary/useful information.
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
(This information will help us with the rehabilitation process and helps keep us safe.)

If you would like, on a separate sheet of paper you are welcome to write a brief or not so brief
history of this horse. This information would only be used to inform potential adopters of this horses
past. Also if you have any preferences for the type of adoptive home you would like to see this horse
go to, let us know. We cant promise specifics when placing horses into new homes; however we do
try to take into consideration the type of home owners would like to see their horse go to.

Release:
I,_________________________________________, agree that the above information is true
to the best of my knowledge and that I am the legal owner of the above described horse. I understand
that by signing this form, I agree to surrender legal ownership of my horse(s) listed above to Equine
Salvation. I have read and thoroughly understand this release of liability and agree to abide by it.
Signed:_________________________By:_________________________Date:_________________
Owner

Printed Name