1. Who in your town is responsible for the maintenance of:
A. Schoolyards or outdoor play areas? ____________________________________
B. Athletic fields? _____________________________________________________
C. Parks? ___________________________________________________________
(Examples: Schools, town recreation or parks departments, sports associations, lawn care companies)
2. Based on a phone call, personal contact, E-Mail or letter correspondence with any of the above:
A. Are lawn chemicals (herbicides/fertilizers, pesticides, etc.) used on these properties?__________
B. If so, at which facilities, which chemicals are being applied, and by who?
(List by brand name and/or by specific chemicals).
children are present or will be on the premises soon?
3. List phone numbers & E-Mail addresses for any persons with whom you spoke, or for appropriate decision makers in your town. (We will provide information to them on the hazards of these chemicals and on alternative lawn care practices that are healthier and can save money.)
4. Have you, your child, or anyone you know ever noticed a negative reaction to any lawn application?
Yes No Some Not Sure
5. If so, which product or chemical, and what kind of reaction did you have?
YOUR NAME: PHONE:
REASON FOR INTEREST IN THIS CONCERN: