1. Paste and copy this form onto your
computer
2. Fill it out
3. Send it back by
e-mail
or by mail to Miller's, PO Box 14254,
SLO CA, 93406
|
Miller’s Equestrian
Center and Sanctuary
EQUINE DONATION CONTRACT This questionnaire is designed to provide us with as much information as possible about the horse(s) you are placing into our program. Your donation ensures that the horse will always have a loving home. And your donation is tax deductible (fair market value of the horse). We are a 501c3 non profit organization registered with the federal government.
1. Your name __________________________________________________
Address ____________________________________________________
City, State, Zip _______________________________________________
Phone ______-________-___________ Fax ______-________-______
Second phone number (e.g. work/cell): ____-_____-___________
E-mail address _______________________________________________
2. Horses registered name (required if registered) __________________________________ Date foaled ________
Nickname ______________________________
Sire __________________________________ Dam ______________________
If the horse is a grade horse, what do you know about his/her parentage? ____________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
Breed ________________________________ Age ____________ Sex ______
Height _________________ Weight ________________ Color ____________
Markings__________________________________________________________
Scars_____________________________________________________________
Are you the owner of record? _______ If no, who is? ___________________________
Address of Owner (if you are not the owner of record: __________________________________________
__________________________________________ phone #: ______-________-______________ NOTE: Owner of record or authorized agent, must sign this form AND the owner of record OR authorized agent’s information must appear in question #1. Where is the horse currently stabled? ___________________
If stabled at your home/farm, how long has the horse been there?________________________
What is the current turnout situation for your horse? ________________________________
_____________________________________________________________________________________________
Is this what the horse is used to? _____________________ If no, explain: __________________________
____________________________________________________________________________________________
If currently stabled somewhere other than your farm/home, provide the following information:
NAME OF FACILITY WHERE HORSE IS CURRENTLY STABLED: ________________________
HOW LONG HAS HORSE BEEN AT THIS FACILITY? __________________________________
ADDRESS OF FACILITY: __________________________________________________________
__________________________________________________________
PHONE: ____-_____-__________ CONTACT PERSON: __________________________
IF HORSE HAS BEEN AT CURRENT FACILITY LESS THAN THIRTY DAYS, WHERE WAS HORSE STABLED PRIOR TO THIS (NAME, ADDRESS, PHONE)? _______________________________________________________________________________
3. Registration/tattoo/brand number/chip id: (Required) ________________ Association: _______________
For Thoroughbreds, you must include the registration papers as we receive a grant from Blue Horse Charities (www.bluehorsecharities.org) and Thoroughbred Charities of America (www.thoroughbredcharities.org) each year based upon the registered Thoroughbreds we place into new homes. Directions for signing the horse over to Bright Futures Farm are at the end of this contract.
4. Is the horse sound? ___________________ If no, please explain __________
_________________________________________________________________
Date the horse was last ridden:___________________type of riding done: _________________________________
5. If the horse you are placing with us is recuperating under a veterinarian’s instruction, or has been sick or injured in the past, please notify your veterinarian and farrier in writing, that you authorize the release of their records for your horse to Miller’s Equestrian Center and Sanctuary. This information will ensure that we continue any treatments that they may have started, and will allow us to determine what progress the horse is making with respect to specific treatment. Please authorize our vet (Liz Bracken 6905 Llano Rd., Atascadero, CA 93422) to obtain access to any x-rays or ultrasounds that have been done to assist us and our veterinarian with continued treatment. This information helps us keep expenses at a minimum, and provides a starting point for our vet for ongoing physical issues. To expedite our receipt of this information, you may contact your veterinarian and farrier requesting that they forward all records (and x-rays, etc., where applicable) to Liz Bracken 6905 Llano Rd., Atascadero, CA 93422. And, please provide us with the following information (if the horse is being treated at this time).
Veterinarian ___________________________________ phone __________________
Veterinarian ___________________________________ phone __________________
Farrier ________________________________________ phone __________________
Farrier ________________________________________ phone __________________
6. Please attach a copy of the current coggins. Must be no less than six months old. If horse is being transported across state lines, we will also need a Health Certificate. Health Certificates must be issued within thirty days of transport date.
7. Please list all vaccinations the horse has had within the last twelve months, and the date of administration
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
8. Has the horse ever worn corrective shoes? ______ Explain ___________________
______________________________________________________________________
9. Has the horse ever had surgery? _______ Explain ___________________________
10. Has the horse ever had colic? ______ Explain ______________________________
11. Do you wish to be provided with periodic updates regarding the horse you have donated? ___
12. What is the degree of schooling the horse has had to date? __________________________________________
____________________________________________________________________________________________________ 13. Please check all that apply:
This horse will/is . . . ____Stand tied ____Stand in cross ties ____Kick ____Walk with you ____Come when called ____Strike ____Bite ____Load/unload ____Well Mannered ____Crib ____Know leads ____Easily trained ____Good w/other horses ____Child safe ____Picks up feet ____Good w/vet ____Bucks ____Spooks easily ____Has foundered ____Jumps ____Has colicked ____laid back ____Has had navicular pbs ____Has had stifle pbs ____Gaited ____Likes people ____Sensitive skinned ____Clumsy ____Clips ____Bathes ____Sensitive feet ____Even tempered ____Arthritic ____Good alone ____Needs companion ____Longes ____Trained to ride ____Trained English ____Trained Western ____Good in stall ____Drives ____Fully halter broke
14. Has the horse ever had a virus/disease? ____ explain (and provide dates) ____________________________________________________________________________________________
15. Is the horse sensitive to specific weather (i.e. sun, cold)? ______________________
Is the horse used to being blanketed in the winter? ______ At what temperature do you
blanket him/her? ___________________________________________________
16. Has the horse ever been lame? ____ explain (again provide dates)_______________________
________________________________________________________________________
17. Does the horse have any sensitive areas on its body? _________________________
________________________________________________________________________
18. Has the horse ever had a prolonged illness/injury (more than 30 days)? _______
explain (please provide dates)_____________________________________________________________
Has the horse been ill in the last sixty days? Explain: ________________________________________
___________________________________________________________________________________________
19. Does the horse have any known allergies? __________________________________________________
20. Does the horse have a history of hives? ___________ explain __________________________________
___________________________________________________________________________________________
21. Current feed/times/amount _________________________________________________________________
What supplements, if any does your horse receive, and how often?_______________________
__________________________________________________________________________________________
22. What does the horse do when scared? ______________________________________________________
Does the horse have any issue with loading/unloading? ________ If so, explain the issue, and
what you do to rectify it? _______________________________________________________________________
___________________________________________________________________________________________
23. What do you consider this horse’s best trait(s) ________________________________________________
_________________________________worst trait(s) ______________________________________________
___________________________________________________________________________________________
“OUR” DEFNINTIONS FOR RIDER/HANDLER SKILL LEVEL:
Each of us has a different interpretation of what a beginner rider/handler is, an intermediate and an advanced individual. It’s all relative to what you’re used to, and what you’ve been taught. Please follow our definitions when you rate your horse in question 33, even though your definition may be different than ours. Beginner: never ridden; ridden well trained, slow, or very forgiving horse; can sit the walk and trot, but may be uncomfortable or stiff due to even minimal fear of a sudden surprise; doesn’t know leg, hand or weight cues well; Can lead a horse, but doesn’t know what to do to discipline if the horse doesn’t just follow along, or decides to go off in his own direction; would panic if a horse tried to pull away, rear or buck; screams or yells when a horse surprises them; doesn’t know the rules of safety with regard to walking, standing beside, working around a horse.
Advanced Beginner/Early Intermediate: knows leg and hand cues, some weight cues. Can sit all gaits relatively comfortably, but may not be able to balance a buck, or know what to do if a horse bolts; Hasn’t developed enough strength in arms to hold a strong horse back; hasn’t developed enough strength in legs to move an obstinate horse or hesitant horse forward; Knows leads; knows how to post; knows how to sit a horse that bucks, even if they aren’t yet able to balance the movement well; may have started over cavelettis; knows safety with regard to handling, walking, working around horses; horse can do something that surprises them, but they don’t get easily rattled, and can sit the issue through and know how to attempt to calm the horse.
Intermediate: Knows cues well; can ride all gaits very comfortably; Can sit a buck; Can sit a rearing horse; knows what to do if holding a horse that rears; knows how to handle a horse that bites or kicks; has strength in arms to handle a strong horse, or stop a bolting horse; Has strength in legs to cue a non responsive horse; may have started jumping and can balance a jump comfortably; doesn’t spook when the horse does and can immediately begin to calm a horse that is afraid; can anticipate changes in behavior when riding or handling a horse and knows how to react to maintain control of the situation.
Advanced: skilled professional. Can do all of the above and more.
I have completed the donor questionnaire, and do hereby certify to the best of my knowledge that the information I have supplied to Miller’s Equestrian Center and Sanctuary about said horse is correct. Furthermore, I warrant that if Miller’s Equestrian Center and Sanctuary accepts my horse into their program, Miller’s Equestrian Center and Sanctuary has a good and clear title to the horse, free from any liens, encumbrances and claims by third parties to said horse. And finally, upon acceptance of my horse into the adoption program at Miller’s Equestrian Center and Sanctuary, I do hereby transfer this horse to the care of Miller’s Equestrian Center and Sanctuary (with or without “papers”), who, in turn, will find a suitable purpose or home for my horse. Your signature confirms the donation and transfer of care of said horse to Miller’s Equestrian Center and Sanctuary.
I have determined the fair market value of the horse I am donating to be: $___________________
I agree that I will provide transport of the horse to Miller’s Equestrian Center and Sanctuary or one of their approved foster facilities if there is an opening. _____________(initials). I understand that there may be a waiting list. If there is a waiting list, you may foster the horse for Miller’s Equestrian Center and Sanctuary until either we have an opening, or the horse is adopted. [Again, all of your expenses directly related to this horse from the date you donate him/her may be tax deductible as a charitable contribution as we are a registered 501c3 charity.]
I have read, understand and assent to the terms and conditions herein. I understand that this document is a binding legal contract, and I further understand that my signature automatically transfers ownership of the horse mentioned herein to Miller’s Equestrian Center and Sanctuary immediately.
__________________________________________________ date ______________ Donor
Thank you for your kindness and generosity
|