MSAD #37

REQUEST FOR NOTIFICATION OF SPECIFIC PESTICIDE APPLICATION

________________________ School

I am a parent/legal guardian or staff member of this school and I want to be notified before specific pesticide applications are made at the school or on the school grounds except the following:

Non-volatile liquids injected into cracks, crevices or wall voids;

Non-volatile baits, gels, pastes and granular materials placed in areas inaccessible to students;

Paints, stains and wood preservatives;

Disinfectants used for routine cleaning;

Non-powered applications of ready-to-use general use pesticides to control or repel stinging or biting insects where there is an urgent need to protect the health or safety of a student, staff member or other school occupant;

When school is not in session and will not be in session until the re-entry time specified on the pesticide label has elapsed; and,

Indoor applications of a pesticide with no re-entry interval specified on its label but entry to the treated area is restricted for at least 24 hours.

I would prefer to be contacted by (circle one): U.S. Mail E-mail Telephone

Name:__________________________________________________________________________

Date:___________________________________________________________________________

Mailing Address:___________________________________________________________________

Daytime Phone:____________________________________________________________________

Evening Phone:____________________________________________________________________

E-mail address:____________________________________________________________________

Return this form to:

SAD #37

PO Box 79

Harrington ME 04643

Approved: September 24, 2003

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