Kentucky Equine Humane Center, Inc.

EQUINE DONOR FORM

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Name: ______________________________________________Date:________________

Address:_________________________________________________________________

City, State & Zip:________________________________________Phone:_____________

Driver's License #_______________________________State:______________________

Equine's name & registration or brand:_________________________________________

Breed: _________________________________________Age: __________Sex:_______

If equine is a mare, is there a possibility she could be pregnant?   _____Yes _____No      

Owner's Initials__________

Please describe the equine's temperament, soundness and any habits about which the Kentucky Equine Humane Center and its adopters should know.

______________________________________________________________________

_______________________________________________Owner's Initials___________

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_____     Owner's Initials_______

Has this equine ever injured anyone?   Yes ____No____   Owner's Initials____________

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 ____Owner's Initials____________

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

Date__________  E & W Encephalomyelitis   
Date__________  Tetanus                         
Date__________  Rhino-Flu                      
Date__________  Rabies                             
Date__________  West Nile                                        
Date__________  Botulism                                  

Date__________  Worming Product_____________________________       

Date__________  Hoof Care                                                         

Date__________  Dental Care                               

 

To the best of my knowledge, the above information is true and correct.

_____________________________                          ________________      
Owner's signature                                                            Date

 

Will you be making a tax deductible donation to help cover the costs of caring for this equine while it is at the Kentucky Equine Humane Center?
__________Yes          __________No          

                                 
         
Equine's name & registration or brand:

       ________________________________________________________________________

I hereby donate the above named equine to the Kentucky Equine Humane Center, Inc., and thereby relinquish all ownership in this animal.  I understand that the Kentucky Equine Humane Center will not be responsible for any financial obligations incurred by the owner(s) on behalf of this equine prior to its donation to the Kentucky Equine Humane Center, Inc.  Should the Kentucky Equine Humane Center find a suitable home: I understand that I am consenting to adoption of the equine by an individual/organization approved by the Kentucky Equine Humane Center.  I understand and agree that I am transferring full ownership of my equine to the Kentucky Equine Humane Center and the Kentucky Equine Humane Center has full authority for all necessary veterinarian procedures including euthanasia.
                                                                                               

______________________________                   ________________________________
Donor                                                                     Kentucky Equine Humane Center          

 

______________________________                     ________________________                        Witness                                                                   Date