Drift Catcher Application

1. Full Name

Full Name

2. Address (Street/City/State)

Address (Street/City/State)

3. Phone Number

Phone Number

4. Email Address

Email Address

5. Why are you concerned about pesticide drift?

Why are you concerned about pesticide drift?

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

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.

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?

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? Yes

Not Sure

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?

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?

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