2022-2023 ANNUAL PESTICIDE NOTIFICATION REQUEST

PARENTS: PLEASE READ AND COMPLETE THE INFORMATION BELOW AND RETURN IT TO YOUR SCHOOL PRINCIPAL

Parents/guardians can register with the school to receive notification or individual pesticide applications. Persons who register for this notification shall be notified at least seventy-two (72) hours prior to the application, except in emergencies, and will be provided the name and active ingredient(s) of the pesticide as well as the intended date of application.

Parents/guardians seeking access to information on pesticides and pesticide use reduction developed by the Department of Pesticide Regulation pursuant to California Food and Agricultural Code section 13184, can do so by accessing the Department’s web-site at www.cdpr.ca.gov.

Student Name:	Date of Birth:	__________________

Address:

City:	Zip Code: __________________

Telephone No.:	Grade: __________________

School:

I would like to be pre-notified every time a pesticide application is to take place at the school. I understand that the notification will be provided at least 72 hours before the application.

I do not need to be notified every time a pesticide application is to take place at the school. I understand that the notification will be posted at least 24 hours before the application.

Signature of Parent/Guardian (if student is under 18)

Signature of Student (if student is 18 or older)