* 1. Full Name

* 2. Address (Street/City/State)

* 3. Phone Number

* 4. Email Address

* 5. Why are you concerned about pesticide drift?

* 6. Have you or your family members been exposed to pesticide drift? If so, please describe.

* 7. Have you or others in your area ever taken action to try to stop pesticide drift from happening? If so, please describe.

* 8. The drift catcher training will be an all-day event on a Saturday or Sunday. The actual pesticide monitoring happens for a week or two during the spring and summer and takes about 10 hours/week to complete. Are you able to make these commitments?

* 9. Are you a member of any organizations that you could involve involve in this effort (examples: farmer organizations, environmental groups, etc.)? If so, which organizations?

10. Is there anything else you'd like us to know about you?

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