Muddy Creek Farms & Rehoming Facility for Unwanted Horses
Surrender Form
Horse Information:
Horse Nickname ___________________________________________________________________________________________________________
Full Registered Name_______________________________________________________________________________________________________
Registration Association and # ________________________________ original breed papers with signed transfers must be submitted with this form
Breed _____________________________________________ Age ___________________ Gender________________________________________
Color______________________________________________________________________________________________________________________
Descriptive Markings and Brands ___________________________________________________________________________________________
____________________________________________________________________________________________________________________________
Current Owner Information:
Current Owner ____________________________________________________________________________________________________________
Street Address________________________________________________________________ City _______________________________________
State ___________________ Zip Code ____________________________ Home Phone ______________________________________________
Cell Phone ___________________________________________________Work Phone _________________________________________________
Email _____________________________________________________________________________________________________________________
How long with current owner? ____________________________________________________________________________________________
Who owned prior to current owner? (If known) _____________________________________________________________________________
Reason for surrendering horse to Muddy Creek Farms & Rehoming Facility for Unwanted Horses ____________________________
____________________________________________________________________________________________________________________________
Medical and Temperament History:
Most recent vaccinations including date administered: _____________________________________________________________________
Most recent worming including date administered and product used: _______________________________________________________
Does this horse have a current negative Coggins test? ___________ (if so, original Coggins test must
accompany this form)
Has this horse been vaccinated for West Nile Virus within 6 months? ________________
Stand tied? _______________________ Load into a trailer? ________________________ Lead?_________________ Clip? _________________
Stand for the hose? _______________________________________________ Stand for the farrier?_____________________________________
Stand to be wormed/vaccinated? __________________________________________________________________________________________
Known unsoundness, lameness, or other medical conditions: ________________________________________________________________
____________________________________________________________________________________________________________________________
Current treatment or veterinarian recommendations: ________________________________________________________________________
____________________________________________________________________________________________________________________________.
Any known feed or medication allergies? ___________________________________________________________________________________
____________________________________________________________________________________________________________________________.
Please list all known special needs, overall temperament, any likes/dislikes, quirks, vices,
or other useful information: _________________________________________________________________________________________________
____________________________________________________________________________________________________________________________.
____________________________________________________________________________________________________________________________.
____________________________________________________________________________________________________________________________.
On a separate sheet of paper, please write up a short history of this horse. 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 can't promise specifics when placing horses into new homes, but will try our best.
Release: I , _______________________________________ (Print Name) agree that the above information is true to the best of my knowledge. I understand that by signing this form, I agree to surrender legal ownership of my horse(s) listed above to Jennifer Seifert and Patricia Boyer of Muddy Creek Farms & Rehoming Facility for Unwanted Horses. It is understood that the surrendering party shall hold Jennifer Seifert and Patricia Boyer and all their officers, directors, employees, and volunteers harmless from any claims of damage, injury, or acts of negligence arising from this surrender. I have read and thoroughly understand this release of liability and agree to abide by it.
I fully understand that Muddy Creek Farms & Rehoming Facility for Unwanted Horses is not a non profit facility. I understand that Muddy Creek Farms & Rehoming Facility for Unwanted Horses does NOT retain ownership of said horse when adopted out to a new home.
*DO NOT SIGN FORM UNTIL YOU SURRENDER THE HORSE*
Owner____________________________________________________________ (Signature) Date_________________________________________
Muddy Creek Farms & Rehoming Facility for Unwanted Horses ____________________________________________ (Jennifer Seifert OR
Patricia Boyer) Date ____________________________
Please mail this to: Muddy Creek Farms & Rehoming Facility for Unwanted Horses, 745 Possum Hollow Rd, East Berlin, PA 17316
Or return it at time of surrender