MARE HEALTH FORM    

                                                                                                                                                                   Date:                                

Mare Owner agrees to breed the Mare,                                                                    , Reg. No.                                       , Breed                                   ,   Age                    , Color                       , to the Stallion                                                        , AQHA #                                 , with Shipped Semen from that Stallion, subject to the following conditions:

To facilitate our records, please fill out applicable information below and return promptly.

Mare’s Breeding: Sire/ Dam                                                                                                             
Sire of Foal                                                                                       
Foaling Date                                                      

Vaccinations                            Yes      No                              

Mares only:

Pneumabort      5/7/9 months                                                   

Flu                                                        

Encephalomyelitis                                  

Tetanus                                                 

Wormings

Date last wormed                                

Foals Only:

Tetanus Antitoxin                                                                 
Date last wormed                                                

Mare’s Breeding History                                                       Special Instructions

Dates of previous breedings                                                                                       

Breeding complications?                                                                                            

Post-foaling infusions?                                                                                               

Post-breeding infusions?                                                                                           

Dates of previous foaling:                                                                                           

Insurance Company                                                                
Contact person                                                                          
Amount Insured                                                                          
Insurance Co. Phone number                                                  

Waiver of Liability:  It is understood that Messick Quarter Horses at Pine Ridge Acres, Brenda and/or Thomas Messick, and /or Employees shall not be held liable for any accident, injury, loss, damage sickness to and/or death of the above named horse, owner and/or participant in equine activities resulting from the inherent risk of equine activities and/or to any damage to and/or loss of owner’s personal property. Owner, or legal guardian,  is responsible for full and complete insurance  coverage on the owner, above named horse, and/or personal  property.

                                                                                                                
Mare Owner’s (or authorized agent’s) Signature  Date

                                                                                                                
Brenda Messick (or authorized agent’s) Signature        Date

Mare Owner’s Name:                                                                             
Address:                                                                                                  
City, State, Zip Code:                                                                             
Phone:  (                      )                                                                                     

WARNING! Under Nebraska Law an equine professional is not liable for an injury to or the death of a participant in equine activities resulting from the inherent risks of equine activities, pursuant to sections 25-21, 249 to 25-21, 253 N.R.S.

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