IPM Notification Request

Parent Name

Student Name

Address Line 1

Address Line 2

City

Zip

Day Phone

Evening Phone

Email Address

Please Check One: I wish to be notified prior to a scheduled pesticide application _____ of the school building. Inside Outside Inside and Outside

Sites of Interest Entire District Midway Dimondale Elliott Horizon Sycamore Wilcox Hope Washington Woods Holt Junior High Holt High School - Main Holt High School - North Transportation