PORTAGE COUNTY RANDOLPH FAIR 4H HORSE PROJECT INOCULATION FORM
Due July 28
In order for a horse or pony to attend fair, THIS FORM MUST ACCOMPANY ALL SHOT RECORDS.
One animal per form. Fill out form completely and provide required signatures.
Influenza types I and II shots must be given between June 1 and July 28. Horse owners giving their own shots
must provide a receipt from buying the shots as well as a signature from the club advisor confirming that the
horse received the shot in order for stalls to be assigned.
If flu shots are given before June 1, please give a booster shot to go to fair.
4H Member’s Name _________________________________________________________________________
4H Club Name _____________________________________________________________________________
Animal’s Registered Name ___________________________________________________________________
Animal’s Nickname _________________________________________________________________________
(Circle answers):
Horse Pony
Mare
Type of Shot
MANDATORY SHOTS
Gelding
Stallion
Animal’s Age _______
If given by OWNER:
Signature of owner required:
Flu A2
RECOMMENDED SHOTS
Rabies
Eastern/Western Encephalomyelitis
Receipts for purchase of shots MUST be
attached
___________
Advisor’s signature required to confirm shot
was given by owner.
_________________________ Owner’s Signature
Rhino
________________________ Advisor’s Signature
Tetanus
_______________________________ Date Given
West Nile virus
OR
Other:
If given by VET:
Attach the vet’s bill showing 4Her’s name and
horse’s name.
______________
2/16/16 updated