Horse Surrender/Relinquishment Form

General Information (All fields must be completed. If non-applicable, enter n/a.)

Legal Owner: ________________________________________________________

Address: ___________________________________________________________

City: ___________________ State: _______________ Zip: ________________ 

Home Phone: (_____) _____-_______

Alternate Phone: (_____) _____-_______ 

Email Address: ______________________________________

Alternate Email: _____________________________________ 

If equine is boarded at a different location please complete the following section:

Physical address/location of equine:

Address: _______________________________________________________________

City: ___________________________ State: ______________ Zip: _______________ 

Name of Property Owner: _________________________________________________

Contact Number for Above Property: ________________________________________ 

How many animals are being Surrendered/Relinquished? _________________________

(If more than one, use Addendum)

Equine Information (All fields must be completed. If non-applicable, enter n/a.). 

Equine Name: _________________________ Breed: _______________________

Age: ________________ Sex: __________________

Color, Markings, Brands, Etc: ____________________________________________ 

Date of Surrender: _______________________ Relinquish Fee: ___________

Current negative Coggins? (circle one) Yes No 

Current Vaccinations? (circle one) Yes No

*Note: Current Coggins form and records of vaccinations must be attached if applicable.

Current equine worming program: __________________________________________ 

Date last wormed and type of wormer: _______________________________________ 

Current Feeding Program: _________________________________________________

Date and time last fed: ____________________________________________________ Type of feed: ____________________________________________________________

Veterinarian’s Name: _____________________________________________________

Phone Number: (_____) _____-_______ 

Reason for Surrender/Relinquish: __________________________________________ ______________________________________________________________________ 

Special Needs, instructions or information/Notes on equine: ______________________________________________________________________ ______________________________________________________________________

______________________________________________________________________

**See Attached Addendum if Additional Horses** 

_____ pages have been attached: _______ (intial)

I, _____________________________, declare that I am the sole and legal owner of the above mentioned equine(s) and have the legal right to surrender/relinquish him/her/them to White Phantoms Wild Horse Rescue.

I, the undersigned, agree to surrender/relinquish all ownership, rights and interest in the above referenced equine(s) to White Phantoms Wild Horse Rescue (WPWHR). I certify that no claims or liens exist against said equine(s) to the best of my knowledge. However, if any claims or liens were placed on the equine(s) while in my custody, I assume full responsibility for such and will not hold White Phantoms Wild Horse Rescue liable. If legal proceedings are initiated against me or White Phantoms Wild Horse Rescue arising from my custody or care of said equine(s), I agree to assume full responsibility and hereby release White Phantoms Wild Horse Rescue from all liability.

In signing this form, I attest that I am voluntarily and without duress releasing custody of the above referenced equine(s) completely and fully, to White Phantoms Wild Horse Rescue (WPWHR). I understand that in certain cases, WPWHR policies do not fully address specific or unforeseen situations, WPWHR will determine what is necessary and take such action, to the best of their ability, so as to ensure that the best interests of the equine(s) are met.

*If Applicable* I further understand that the returned equine(s) must have official documentation of current negative Coggins and documentation of currency on all vaccinations required by WPWHR policy or these expenses may be charged to me. 

No amendment or variation of this contract shall be effective unless in writing and signed by or on behalf of each of the parties hereto. 

I understand that once I have surrendered/relinquished the above said equine(s) I will have no rights of ownership. ______________ (initial) 

I understand and agree to make an appointment if I would like to come and visit the equine(s). ___________________ (initial)

I understand that at no time am I allowed to visit WPWHR facilities without prior permission from WPWHR. ________ (initial)

I understand that if I enter WPWHR property without permission I may be arrested for Trespassing. ___________ (initial)

Print Name: _____________________________ Date: ______________

Signature of Legal Owner:_________________________________________________ 

Driver’s License Number: _______________________Issuing State: ____________

WPWHR Representative Signature: _________________________________________ 

Date: ______________ 

Addendum to WPWHR Surrender/Relinquish Form

Equine Information (All fields must be completed. If non-applicable, enter n/a.). 

Equine Name: _______________________ Breed: ____________________________

Age: ________________ Sex: ____________________

Color, Markings, Brands, Etc:____________________________________________ 

Date of Surrender: _______________________ Relinquish Fee: ___________

Current negative Coggins? (circle one) Yes No 

Current Vaccinations? (circle one) Yes No

*Note: Current Coggins form and records of vaccinations must be attached if applicable.

Current equine worming program: __________________________________________ 

Date last wormed and type of wormer: _______________________________________ 

Current Feeding Program: _________________________________________________

Date and time last fed: ____________________________________________________ Type of feed: ____________________________________________________________

Veterinarian’s Name: _____________________________________________________

Phone Number: (_____) _____-_______ 

Reason for Surrender/Relinquish: __________________________________________ ______________________________________________________________________ 

Special Needs, instructions or information/Notes on equine: ______________________________________________________________________ ______________________________________________________________________

______________________________________________________________________