As part of the Bolivar-Richburg Central School District’s pest management program, pesticides are occasionally applied.  You have the right to be informed prior to any pesticide application made to the school grounds and buildings.  In certain emergencies, pesticides may be applied without prior notice, but you will be provided notice following any such application.  If you need prior notification, please complete the information below and submit to:

Mr. Randy Harmon, Superintendent of Buildings & Grounds
Bolivar-Richburg Central School
100 School Street
Bolivar, NY  14715

Pesticides use Prior Notification Request

(Please Print)

Parent/Guardian Name:________________________________________________

Child’s Name:_______________________________________________________

Street Address:______________________________________________________

City:_______________________________    ZIP Code:______________________

Telephone Numbers:    Daytime_________________    Evening_______________ 

Please Check One: 

_____    I wish to be notified prior to a scheduled pesticide treatment inside of the

              building.

_____    I wish to be notified prior to a scheduled pesticide treatment on the grounds

              of the school.

_____    Both of the above.

__________________________________________            ________________

Signature                                                                                 Date