Back in the Saddle Horse Adoption, Inc.

Donation Application

This form is to be used to describe the horse you wish to donate to Back in the Saddle Horse Adoption, Inc. (BITS). It is designed to provide us as much information as possible so that we can find the best home for your horse. Please answer all questions truthfully and be sure you understand your obligations and rights before signing this form. To finalize the donation, you will have to sign the Donation Contract transferring ownership of the horse to BITS. Please be sure all paperwork is completely filled out and signed before submitting to us.

DONOR INFORMATION

Name: ________________________________________________

Address: ________________________________________________________________________________________________

City: ____________________________________________

State: _______________

Zip: _________________

Phone (home):_____________________

Phone (other):_____________________

E-mail address: ___________________________________

Fax: _____________________

HORSE INFORMATION

Registered name: __________________________

Barn name: ___________________

Age: ___________ Date Foaled: ________________

Sex: _________________

Color: ________________

Markings: ______________________________________

Breed: ________________________

Registries: _____________________________

Tattoo: ________________________

Electronic ID #: _________________________

Height (Hands): _________________

Weight (lbs): ___________________

Current location of horse: _________________________________________

State: _____

Estimated value (US $): ____________________

HEALTH RECORD AND HISTORY

Veterinarian name: ________________________________ Phone: ______________

List any known allergies: ________________________________________________

Describe any surgeries (with date of occurrence)

________________________________________________

Describe any fractures (with date of occurrence)

________________________________________________

Does the horse have or has it ever had any of the following? Check all that apply:

___colic ___navicular ___laminitis/founder

___bowed tendon ___ringbone ___stringhalt

___back problems ___arthritis ___suspensory injury

___bone chips ___EPM ___EPSM____HYPP

___heaves/COPD ___blindness ___asthma/allergies

If you checked any of the above, please provide a brief explanation with date of occurrence:

________________________________________________

Describe any injuries & illnesses not listed above that required rest or medication for longer

than 30 days (with date of occurrence):

________________________________________________

________________________________________________________________________________________________

Do any of the illnesses or injuries affect the horse's soundness or ability to be ridden? If so,

explain:

________________________________________________

Are there any other physical issues or conformational flaws that affect the horse’s ability to be

ridden? If so, explain:

________________________________________________

Check vices or problems that the horse has:

___biting ___kicking ___charging

___rearing ___bolting ___spooking

___pulling back when tied ___cribbing ___pawing

___attacking other horses ___claustrophobic ___herd bound

___difficult to lead

Please tell us the last date each of these was completed:

Vet examination: _________________________________

Coggins test (EIA): ________________________________

Last Wormed: ____________________________________

Type of wormer used: ________________________________________________

What’s your worming schedule? ________________________________________________________________________________________________

Dental exam: ____________________________________

Teeth floated: ____________________________________

Wolf teeth pulled: _________________________________

Date last bred: ___________________________________

Sheath cleaned: __________________________________

Date of last foal: __________________________________

Feet trimmed: ____________________________________

Feet shod: _______________________________________

Type of shoes worn: _______________________________

Circle One: Full set Front only

Does the horse have any special shoeing / trimming requirements? Please explain:

________________________________________________________________________________________________

________________________________________________

Vaccination record (please indicate date of last shot):

Eastern & Western Encephalitis: ____________ Rhinopneumonitis: ____________

Influenza: ____________

Strangles: ____________

Rabies: ____________

Tetanus: ____________

Potomac Horse Fever: ____________

Botulism: ____________

West Nile Virus: ____________

TRAINING HISTORY

Best traits of horse: ________________________________________________________________________________________________

________________________________________________

Worst traits of horse: ________________________________________________________________________________________________

________________________________________________

Check all that apply about the horse:

___likes people ___good manners ___good temperament

___respects handler’s space ___confident ___high energy

___low energy/laid back ___nervous ___timid

___smart ___loads ___quiet in stall

___lunges on line ___free lunges ___ties

___cross ties ___clips ___bathes

___good alone ___good w/other horses ___leads quietly

___can catch in open field ___good with children

___good with farrier ___high in pecking order

___good with vets/shots ___low in pecking order

How often is horse currently being ridden(days per week):

If not currently ridden on a regular basis, when was the last time the horse was ridden? ___________________________________________

Please tell us the size and type of tack this horse is accustomed to:

Type saddle: Western English Racing Saddleseat

Other __________________________________________

Saddle tree size: __________________________________

Type of bridle: Western English

Other: __________________________________________

Type of bit used:__________________________________

Size: ___________________________________________

Size and type of harness: ________________________________________________

Does the horse have any girthing / saddling / harnessing / bridling issues?

________________________________________________________________________________________________

What is the professional/personal experience of the horse, including current job? Explain all experiences in years/months include breeding, racing, showing, riding, driving (attach show record if applicable). If professionally trained, provide trainer’s name.

________________________________________________________________________________________________

Check all the professions you believe the horse can do now or with training:

___English Pleasure ___Trail Riding

___Huntseat on the flat ___Endurance Riding

___Equitation over fences ___Western Pleasure

___Hunter over fences ___Low Level Jumping

___Upper Level Jumping ___Low Level Eventing

___Upper Level Eventing ___Working Farm or Ranch

___Low Level Dressage ___Upper Level Dressage

___Pony Club or 4-H ___Lesson or School Horse

___Fox Hunting ___Lead Line w/Young Child

___Other Western ___Western Performance (circle applicable) reining cutting roping

Other: ________________________________________________________________________________________________

Are there any professions that you feel the horse cannot do or should no longer do? If so, explain:

________________________________________________________________________________________________

________________________________________________

Recommended minimum level of experience of handler on ground? _________________________________________

Recommended minimum level of rider? ________________________________________________

Please tell us how the horse has been stabled and fed:

Type of grain: _________________________

Brand: __________________________

Amount: _____________________________

Times fed per day__________________

Type of hay: __________________________

Amount: _________________________

Describe all that apply:

___easy keeper ___hard keeper ___slow eater

___picky eater ___history of choking ___protective of feed

List any drugs, vitamins or supplements the horse is currently taking:

________________________________________________

________________________________________________________________________________________________

Is the horse presently stalled? __________________________________

Type of bedding (e.g., sawdust, straw): ________________________________________

How often is the horse currently turned out? ____________________________________

What type of fencing is the horse accustomed to? ________________________________________________

________________________________________________

Has the horse ever lived outside in a run-in situation in snow and winter for extended periods of time with temperature at freezing or below? Y N

Is this horse accustomed to wearing a blanket or sheet? Y N

At what temperature is the blanket worn? __________________________________

Blanket Size: ___________

Blanketing Schedule: _________________________

Tell us how this horse is accustomed to being transported:

___2 horse straight load with ramp ___stock trailer

___2 horse straight load step up ___slant load

___van/tractor trailer with ramp

What is the longest trip this horse has taken?

Hours _____

Miles _____

How do you handle loading or traveling issues with this horse? ________________________________________________

Date the horse was last loaded and transported in a trailer? ___________________

Please tell us anything you think we should know to help us find the best adoptive home for your horse:

________________________________________________

________________________________________________________________________________________________

________________________________________________

Where would you like the horse to be cared for until it is placed?

____Your location ____BITS Main Facility

If you want the horse to stay at our BITS Facility, it is your responsibility to transport the horse. We also require $225 per month towards the care of the horse until the horse is placed. The first month is due upon the horse’s arrival.

Will you pay $225/month for the care of the horse until the horse is placed? Yes No

Would you like BITS to provide your name and telephone number to prospective adopters so that they can contact you directly? Yes No

I am the legal owner of the horse described above. No other person or other entity has any right or claim to the horse, and the horse is free and clear of all financial obligations (including training fees, board, farrier and vet bills).

I understand that to finalize the donation I must sign the Donation Contract transferring ownership of the horse to BITS. I certify that the above information is true and accurate to the best of my knowledge.

Signature: ___________________________________ Date: _________

Please mail or fax your completed Donation Application and Donation Contract to us. We will contact you to finalize arrangements.

Back in the Saddle Horse Adoption, Inc.

C/O Joni Fink

8613 N Route 220 HWY

Linden, PA 17744

Fax: 866-869-6861