South Ridge Elementary School Union Ridge Elementary ... - AWS
REQUEST FOR PRE-NOTIFICATION OF PESTICIDE APPLICATION FORM 2015-2016 (Optional Opt-In) To request pre-notification of pesticide application pursuant to RCW 17.21, please complete this form (one form per family) and return it to the school office. If this form is not completed and filed with the district, it will be assumed that you do not wish to be notified of pesticide application at the school district facilities listed below for the remainder of the current academic year. A request for pre-notification form must be completed each academic year. You may revoke this request in writing by filing consent with the school office.
CHECK ALL BOXES BELOW THAT APPLY:
South Ridge Elementary School Union Ridge Elementary School View Ridge Middle School Ridgefield High School
Parent / Guardian / Staff Name: (please print)
__________________________________________________________________________________________________ Last First School Attends / Works
Parent / Guardian / Staff Signature
Date
CHECK ALL BOXES BELOW THAT APPLY:
South Ridge Elementary School Union Ridge Elementary School View Ridge Middle School Ridgefield High School
Parent / Guardian / Staff Name: (please print)
__________________________________________________________________________________________________ Last First School Attends / Works
Parent / Guardian / Staff Signature
Date
