Integrated Pest Management Registration
Form
If you would like to receive notification of pesticide use for a
specific school or administrative site, please fill out and return
the notification request form to that site.
Notification requests are kept at the school or administrative
site.
PESTICIDE NOTIFICATION
REQUEST FORM
School:
___________________
Name:
___________________________________________________________
(Parent/Guardian or Interested
Person) |
| Address:
______________________________________________________
______________________________________________________
______________________________________________________
|
| Telephone: Day:
Night: |
| Student
Name:
(if applicable or individual
requesting notification)
|
| Is the student (or
individual) on the Washington State Registry? Yes › No › |
| Do you want
notification of Outdoor Pesticide Use? Yes › No › |
| Do you want
notification of Indoor Pesticide Use? Yes › No › |
| Principal’s
Signature: ____________________________________________ |
Please return this request to the
principal.
Page Updated
3/30/00
tsalmon@seattleschools.org
