RFP snow removal for Southington PD.pdf

Department of Police Town of Southington, Connecticut

Town of Southington

Request for Proposal

Snow Plowing and Ice Control Services

Police Department Facility

2025–2026 Winter Season

1. Intent and General Information

The Town of Southington seeks bids from qualified snow removal contractors to provide snow plowing, snow clearing, and ice control services at the Southington Police Department facility located at: 69 Lazy

Lane Southington, CT

The Police Department is a **24-hour, 7-day-per-week emergency operations facility**. The facility must remain accessible during snow and ice events for police personnel, emergency vehicles, employees, detainee transport, vendors, visitors, and members of the public.

The intent of this Request for Proposal is to secure a qualified, properly equipped, and reliable contractor with sufficient staffing, equipment, salt supply, and backup capacity to maintain the facility in a safe and passable condition during winter weather events.

This facility cannot wait until the end of a storm to be serviced. Snow and ice control services must occur before, during, and after storms as conditions require.

2. Bid Submission Information

Submission Location: https://home.planetbids.com/

Bid Opening: September 24th, 2026 @ 12:00pm

Bid Submission Deadline/closing: September 30th, 2026 @ 12:00pm

Headquarters: 69 Lazy Lane Southington, CT 06489 Tel: 860.378.1600 Fax: 860.378.1605 Email: Chiefdaly@SouthingtonPolice.org

Chief of Police John F. Daly https://home.planetbids.com/

Authorized Contact: Lieutenant Matthew Hammell

Southington Police Department

69 Lazy Lane Southington, CT

Phone: 860-378-1670

Email: Mhammell@southintonpolice.org

***All questions concerning this RFP shall be submitted in writing or e-mailed to the authorized contact listed above. ***

3. Contract Term

The contract shall begin on or about: October 1, 2026 or upon the first required snow plowing, snow clearing, salt, or ice control event occurring thereafter, whichever occurs first.

The contract shall remain in effect through: April 1, 2027

The Town may, at its discretion, include an option to renew for additional winter seasons by mutual written agreement, subject to satisfactory performance, funding availability, and approval by the Town at the already agreed upon rates approved within the awarded bid with no increases.

4. Scope of Services

The contractor shall furnish all labor, supervision, equipment, materials, salt, transportation, and services necessary to perform snow plowing, snow clearing, and ice control services at the Police

Department facility.

Services shall include, but are not limited to:

1. Plowing all designated parking lots, drive lanes, entrance lanes, exit lanes and paved vehicular travel areas.

2. Maintaining emergency access areas in a safe and passable condition.

3. Applying salt after plowing operations as conditions require.

4. Applying salt during icing conditions, including freezing rain, sleet, black ice, refreeze, and other hazardous surface conditions, even when plowing is not required.

5. Clearing and salting all sidewalks, walkways, ramps, stairs, entrance aprons, and pedestrian access areas used by employees and the public.

6. Maintaining public entrances, employee entrances, emergency access routes, and other designated access points during active storms.

7. Performing repeated service during prolonged storms as necessary.

8. Performing final cleanup after the conclusion of a storm.

This contract **does not include off-site snow removal, hauling, or disposal**. Snow shall be pushed and stacked only in areas designated by the Police Department representative. If snow piles later need to be removed from the property, that work will be performed by Town personnel or separately authorized by the Town.

5. Critical Facility Priority Requirement

The Police Department facility shall be treated as a **priority snow and ice control location**.

The contractor shall not delay service until the conclusion of a storm. The contractor must maintain the facility during active winter weather events so that primary travel lanes, emergency access points, employee access areas, public access areas, and pedestrian routes remain reasonably safe and passable.

The contractor shall provide sufficient personnel and equipment to meet the operational needs of a

24/7 emergency facility.

The Town expects reliable service during overnight hours, weekends, holidays, and periods of heavy snowfall or icing.

6. Service Triggers and Response Requirements

A. Snow Events: The contractor shall commence plowing when snow accumulation reaches approximately **one inch**, or sooner if conditions require service to maintain safe and passable access.

The contractor shall continue to return and service the property during the storm as often as necessary to maintain passable conditions.

B. Ice Events: The contractor shall apply salt when icy conditions exist or are reasonably expected, including but not limited to: Freezing rain, Sleet, Black ice, refreeze after melting, Rapid temperature drops, Packed snow or ice, Hazardous walking or driving surfaces, other conditions requiring ice control.

Salt application may be required even when there is no plowable snow.

C. Response Time: The contractor shall respond within **one hour** of trigger conditions or notification by a Police Department representative. The contractor is expected to monitor weather conditions independently and initiate service when conditions require it. The Town should not be required to call the contractor for every snow or ice event.

7. Continuous Storm Coverage: During heavy, prolonged, or rapidly accumulating snowfall, the contractor shall provide continuous or repeated service as necessary to maintain the facility in a safe and passable condition. The contractor shall have sufficient equipment and staffing available to meet this requirement. If necessary to maintain safe and passable conditions, the contractor shall assign dedicated or continuous service coverage during the active storm period.

The contractor’s obligation is performance-based. The contractor must provide enough equipment and personnel to meet the operational needs of the facility, regardless of whether that requires one vehicle, multiple vehicles, backup equipment, additional operators, or repeated returns during the same storm.

8. Minimum Equipment, Staffing, and Capacity Requirements: Because the Police Department is a 24-hour emergency operations facility, bidders must demonstrate that they have adequate equipment, staffing, and backup capacity to perform the work reliably.

Respondents shall submit an equipment and staffing plan with their bid.

At minimum, each respondent shall identify:

1. All plow vehicles available for this contract.

2. The size and type of each plow vehicle.

3. Plow width for each vehicle.

4. Salt spreading equipment available for parking lots and drive lanes.

5. Equipment available for sidewalks, walkways, stairs, and entrances.

6. Backup equipment available in the event of mechanical failure.

7. Number of operators available during snow and ice events.

8. Number of sidewalk/walkway personnel available during snow and ice events.

9. Location from which equipment will be dispatched.

10. Estimated travel time to the Police Department facility during storm conditions.

11. Number and type of other snow accounts serviced by the bidder during storms.

12. Name and contact information for the primary 24-hour supervisor.

13. Name and contact information for a secondary 24-hour contact.

14. Salt supply plan and ability to obtain salt during extended winter weather events.

Small utility vehicles, compact tractors, skid steers, ATVs, UTVs, or similar equipment may be used where appropriate for sidewalks or tight areas, but the respondent must have equipment suitable to plow the full parking lot, drive lanes, and emergency access areas in a timely manner.

The Town may reject any bid if the respondent does not demonstrate adequate equipment, staffing, backup capacity, experience, or ability to service a 24-hour emergency operations facility.

The Town is not obligated to award the contract solely on price if the lowest respondent is determined not to be a responsible or qualified respondent for this critical facility.

9. Walkways, Entrances, and Pedestrian Areas:

The contractor shall clear and salt all pedestrian areas serving the facility, including but not limited to:

Public entrance areas, Employee entrance areas, Sidewalks around the building, Walkways from parking areas to entrances, Ramps, ADA access routes, Entrance aprons or other areas on the property designated by the Police Department representative

Pedestrian access points shall be maintained during active snow and ice events and fully cleared and salted during final cleanup.

Snow and ice shall not be allowed to create unsafe conditions at primary entrances or public access areas.

10. Salt Requirement

The contractor shall furnish and apply salt for snow and ice control. Sand shall not be used unless specifically authorized in writing by the Police Department or Town representative.

Salt shall be applied:

1. After plowing, as conditions require.

2. During icing events.

3. During freezing rain, sleet, black ice, or refreeze conditions.

4. On parking lots, drive lanes, access roads, emergency access areas, sidewalks, walkways, stairs, ramps, and entrances as needed. The contractor shall apply salt in a reasonable and effective manner to reduce hazardous conditions while avoiding unnecessary over-application. Salt used on sidewalks, steps, ramps, and entrance areas shall be appropriate for pedestrian areas and concrete surfaces.

11. Final Cleanup Requirement: After snowfall has ended, the contractor shall complete final cleanup of the facility. Final cleanup shall include:

1. Clearing remaining snow from drive lanes and parking areas.

2. Opening parking spaces where practical.

3. Clearing snow from pedestrian routes.

4. Clearing and salting public and employee entrances.

5. Clearing and salting steps, walkways, ramps, and ADA routes.

6. Salting paved vehicular areas as needed.

7. Ensuring emergency access routes remain open.

8. Ensuring snow is pushed to designated snow stacking areas.

Final cleanup shall be completed within **four hours** after the end of snowfall unless storm severity, weather conditions, or operational needs require a different timeframe as approved by the Police

Department representative.

12. Snow Stacking: Snow shall be pushed and stacked only in designated areas approved by the Police

Department representative. Snow shall not be piled in locations that block or interfere with Police vehicle access, Emergency vehicle access, public entrances, Employee entrances, Sidewalks, ADA routes, Fire hydrants, Drainage structures, Gates, Dumpsters, Sight lines, Secure access points, public parking, Building access

This contract does not require the contractor to haul snow off-site. Snow removal from the property, if needed, will be handled separately by Town personnel or by separate written authorization.

13. Site Inspection: Respondents are strongly encouraged to inspect the site prior to submitting a bid.

The respondent is responsible for understanding the layout of the property, including parking areas, access roads, entrances, sidewalks, ramps, stairs, snow stacking areas, drainage areas, curbing, and other site conditions. Failure to inspect the site shall not relieve the contractor of responsibility to perform the work required under this contract.

The Town may conduct a pre-bid walkthrough within any interested contractor during the duration of the bid while it is open. Please arrange walkthroughs with the authorized contact of this RFP.

14. Snow Stakes and Site Protection: The contractor shall coordinate with the Police Department before the winter season to identify curbs, islands, hydrants, drainage structures, signs, gates, landscaping, bollards, or other features that may require marking.

Snow stakes or markers shall be installed where needed and as approved by the Town.

The contractor shall exercise care to avoid damage to pavement, curbing, sidewalks, landscaping, gates, fencing, utilities, lighting, signs, and building features.

15. Contractor Communication:

The contractor shall provide a primary and secondary 24-hour contact person.

The contractor shall be reachable during all winter weather events, including overnight hours, weekends, and holidays.

The contractor shall respond promptly to calls, texts, or emails from the Police Department or Town representative.

The contractor shall notify the Police Department or Town representative of any significant operational issues, including equipment failure, staffing issues, access concerns, salt supply issues, or unusual site conditions.

16. Service Logs and Documentation

The contractor shall maintain service records for each snow or ice event.

At minimum, service records shall include:

1. Date of service.

2. Time of arrival.

3. Time of departure.

4. Approximate snowfall amount.

5. Type of service performed.

6. Areas serviced.

7. Salt application performed.

8. Equipment used.

9. Name of operator or crew.

10. Any unusual conditions or issues observed.

Service logs shall be submitted with invoices or upon request by the Town.

Failure to provide adequate service logs may delay payment.

17. Emergency Re-Work and Failure to Perform

If conditions are unsatisfactory, unsafe, or incomplete, the contractor shall return immediately upon notice from the Police Department representative to perform additional plowing, clearing, or salt application.

If the contractor fails to respond or fails to perform in accordance with the requirements of this contract during a snow or ice event, the Town may take action necessary to protect public safety and maintain facility operations. Such action may include use of Town forces or another contractor.

The Town reserves the right to deduct from payment, withhold payment, terminate the contract, or pursue other remedies available under the contract or law for failure to perform.

18. Damage Reporting and Responsibility:

The contractor shall promptly report any damage caused during snow or ice operations.

Damage may include, but is not limited to:

* Curbs

* Pavement

* Sidewalks

* Signs

* Bollards

* Fencing

* Gates

* Landscaping

* Building features

* Doors

* Lighting

* Utility covers

* Drainage structures

The contractor shall be responsible for damage caused by its operations, equipment, employees, agents, or subcontractors. Damage caused by the contractor shall be repaired at the contractor’s expense to the satisfaction of the Town.

19. Use of Subcontractors:

Subcontractors must be disclosed in the bid.

The contractor shall identify any subcontractor proposed to perform plowing, salting, sidewalk clearing, or other work under this contract.

Use of subcontractors shall not relieve the prime contractor of responsibility for performance.

The prime contractor shall remain fully responsible for all work performed under this contract, including work performed by subcontractors.

The Town reserves the right to reject proposed subcontractors if they do not meet the Town’s requirements.

20. Proposal Preparation Costs:

All costs incurred in preparing and submitting a bid shall be the sole responsibility of the bidder. The

Town shall not be responsible for any costs associated with bid preparation, site inspection, proposal development, or submission.

21. Inquiries and Addenda:

Questions concerning this bid shall be submitted in writing or emailed to the authorized contact listed in this bid document.

Questions must be submitted no later than **four business days** before the bid submission deadline.

Official responses, clarifications, and addenda shall be issued by the Town. No oral statement by any

Town employee or representative shall be considered binding unless confirmed by written addendum.

Bidders are responsible for reviewing and acknowledging all addenda.

22. Insurance Requirements:

The successful bidder shall provide proof of insurance acceptable to the Town prior to the start of work.

Required insurance shall include, at minimum:

1. Workers’ Compensation Insurance as required by Connecticut law.

2. Commercial General Liability Insurance with limits not less than **$2,000,000 per occurrence**.

3. Automobile Liability Insurance with limits not less than **$2,000,000 combined single limit**.

4. Any other insurance required by the Town.

5. Insurance must be Snowplow/contractor specific liability insurance.

The Town shall be named as certificate holder and, where required by the Town, as an additional insured. Insurance certificates must provide notice of cancellation or material change as required by the

Town. Final insurance requirements shall be subject to review and approval by the Town.

23. Indemnification

The contractor shall indemnify and hold harmless the Town of Southington, the Southington Police

Department, and their officers, employees, agents, and representatives from and against claims, damages, losses, liabilities, costs, and expenses arising out of or resulting from the contractor’s performance of work under this contract, except to the extent caused by the sole negligence or willful misconduct of the Town.

24. Respondent Qualifications:

Respondents shall submit the following with their bid:

1. Company name, address, phone number, and email.

2. Name of owner or authorized representative.

3. Name and phone number of primary 24-hour contact.

4. Name and phone number of secondary 24-hour contact.

5. Number of years in snow removal business.

6. Description of similar facilities serviced.

7. Description of municipal, commercial, emergency services, public safety, or institutional snow removal experience.

8. List of equipment available for this contract.

9. List of backup equipment.

10. Number of operators available during storms.

11. Number of sidewalk/walkway personnel available during storms.

12. Description of salt application equipment.

13. Description of sidewalk/walkway clearing plan.

14. Salt supply plan.

15. Location from which equipment will be dispatched.

16. Three references for similar snow removal work.

17. Proof of insurance or statement of ability to provide required insurance.

18. Completed bid pricing form.

19. Completed equipment and capacity form.

20. Completed non-collusion affidavit.

21. Completed respondent acknowledgment and proposal signature page.

**Failure to submit all required forms may result in rejection of the bid as non-responsive. **

25. Measurement of Snow for Billing Purposes

For purposes of determining the applicable billing tier, snowfall accumulation shall be based on the total snowfall for each snow event.

A “snow event” shall mean a continuous period of snow, sleet, or mixed winter precipitation requiring snow plowing, snow clearing, or ice control services at the Police Department facility.

A snow event shall be considered continuous unless there is a break in precipitation of six hours or more, unless otherwise determined by the Town based on weather conditions.

Snowfall accumulation shall be determined by the Town using one or more of the following sources:

1. Measurement taken at the Police Department facility or another nearby Town facility;

2. National Weather Service snowfall reports for the Southington area;

3. Other reliable local weather reporting sources deemed acceptable by the Town.

The Town’s determination of snowfall accumulation for billing purposes shall be final.

Snowfall shall be measured based on total storm accumulation, not the depth of compacted snow remaining on pavement after plowing, melting, salting, drifting, or vehicle traffic.

Multiple visits, repeated plowing, or continued service during the same snow event shall not be billed as separate snow events unless specifically authorized in writing by the Town. The contractor’s price for the applicable snowfall tier shall include all plowing, clearing, and required service necessary to maintain the facility during that snow event, except for separately authorized dedicated/continuous storm coverage or additional services listed in the pricing form.

If snow changes to rain, freezing rain, sleet, or other mixed precipitation, the event shall still be billed according to the measured snowfall accumulation, together with any applicable ice-only or additional salt application charges authorized under the contract.

Snowfall amounts may be rounded to the nearest one-half inch for billing purposes.

26. Change Orders and Contract Modifications

No change to the scope of work, pricing, service requirements, or other terms of this Agreement shall be valid unless approved in writing by an authorized representative of the Town.

The Contractor shall not perform additional work outside the scope of this Agreement with the expectation of additional compensation without first obtaining written authorization from the Town.

Any proposed change order shall include, at a minimum:

• A description of the requested change in work or services;

• The reason for the requested change;

• Any increase or decrease in contract cost;

• The method used to calculate the additional or reduced cost;

• Any effect on the Contractor’s performance obligations; and

• The effective date of the change.

The Contractor shall provide supporting documentation for any proposed additional cost when requested by the Town.

Verbal instructions, field discussions, or requests made by Town employees who are not authorized to modify this Agreement shall not constitute approval of a change order and shall not obligate the Town to additional payment.

In the event of an immediate condition affecting public safety, emergency access, or continued operation of the Police Department, an authorized Town representative may direct the Contractor to perform emergency work before execution of a written change order. Such authorization shall be documented in writing as soon as practicable following the emergency.

Services already included within the Contractor’s bid price, including repeated plowing during the same snow event, required return visits, normal final cleanup, routine salting, and other work necessary to meet the performance standards of this Agreement, shall not be considered additional work and shall not qualify for a change order.

Services specifically identified and priced in the Bid Pricing Form, including any authorized dedicated or continuous storm coverage, shall be considered contract services and shall not require a formal change order when properly authorized in accordance with this Agreement.

No change order shall be used to alter the competitive bid pricing structure or materially expand the scope of the contract in a manner inconsistent with the original bid documents.

For purposes of this section, “authorized Town representative” shall mean the Chief of Police, Police Captain, or other Town official specifically authorized in writing to approve contract modifications.

27. Evaluation and Award

The Town intends to award the contract to the lowest responsible qualified respondent, as determined by the Town.

The Town may consider factors including, but not limited to:

1. Bid price.

2. Equipment capacity.

3. Backup equipment availability.

4. Staffing levels.

5. Experience with similar facilities.

6. Experience with municipal, public safety, emergency services, or institutional facilities.

7. References.

8. Proximity to the facility.

9. Ability to provide timely service.

10. Ability to provide continuous storm coverage.

11. Salt supply capacity.

12. Past performance.

13. Completeness of bid submission.

14. Ability to meet the operational needs of a 24/7 emergency facility.

The Town reserves the right to reject any or all bids, waive informalities, request additional information, conduct reference checks, and award the contract in the best interest of the Town.

The Town is not required to award the contract to the lowest dollar respondent if that respondent is not determined to be responsible, qualified, properly equipped, or capable of meeting the operational requirements of the Police Department facility.

28. Contract Termination

The Town may terminate the contract for unsatisfactory performance, contractor default, failure to respond, failure to maintain required insurance, failure to provide adequate staffing or equipment, repeated service deficiencies, or other failure to comply with the contract documents.

The Town may terminate the contract upon **7 days written notice** for unsatisfactory performance or default.

In the event of a serious failure affecting public safety, emergency access, or Police Department operations, the Town may take immediate action necessary to maintain the facility and may pursue remedies available under the contract or law.

29. Required Forms

The following forms must be completed and submitted with each bid:

1. Attachment A — Bid Pricing Form

2. Attachment B — Equipment and Capacity Form

3. Attachment C — References

4. Attachment D — Non-Collusion Affidavit

5. Attachment E — Bidder’s Acknowledgment and Proposal Signature Page

Failure to submit all required forms may result in bid rejection as non-responsive.

Attachment A

Bid Pricing Form The bidder shall complete all pricing sections below.

The Town may use the unit pricing, or the optional seasonal pricing determined to be in the best interest of the Town. Billing shall be based on the Town-determined snowfall accumulation for each snow event.

Multiple plowing visits during the same storm shall be included in the applicable event price and shall not be billed separately unless dedicated or continuous storm coverage is specifically authorized by the

Town

Full Snow Event Service (plowing, clearing and salting)

Snowfall Amount Price Per Event

0.1" to 2.0" $__________

2.1" to 6.0" $__________

6.1" to 12.0" $__________

Over 12.0" $__________ plus $__________ per additional inch

Ice-only Salt Application no snow plowing Price Per

Event Vehicular areas, sidewalks, walkways, ramps, stairs, and entrances (as many applications as needed to maintain conditions listed in contract stipulations $__________

If requested Dedicated / Continuous Storm Coverage (to be billed in addition to full snow event service)

Hourly Rate

Dedicated plow truck with operator $__________ per hour Additional plow truck with operator $__________ per hour Sidewalk/walkway crew $__________ per hour

Optional Complete Seasonal Price (filling out this portion is optional)

$____________ to cover all snow plowing, clearing, salting under the terms of the contract for the duration of the contract. To be invoiced and billed monthly and would cover all events during this time.

This price would include dedicated/continuous Storm coverage as requested at no extra charge.

Attachment B

Equipment and Capacity Form

Plow Vehicles Available for This Contract

Vehicle

Year / Make /

Model

Vehicle Type /

Size

Plow

Width

Salt

Spreader?

Dedicated to This

Facility?

Backup

Available?

1 Yes / No Yes / No Yes / No

2 Yes / No Yes / No Yes / No

3 Yes / No Yes / No Yes / No

4 Yes / No Yes / No Yes / No

Backup Plow Equipment

Backup Vehicle #

Year / Make / Model

Vehicle Type / Size

Plow Width

Salt Spreader?

Available Within How Many Minutes?

1 Yes / No

2 Yes / No

3 Yes / No

Sidewalk, Walkway, Entrance, Ramp, and Stair Equipment

Equipment

Equipment Type

Intended Use

Salt / Ice Melt Capability?

Backup Available?

1 Yes / No Yes / No 2 Yes / No Yes / No 3 Yes / No Yes / No 4 Yes / No Yes / No

Staffing Available During Snow and Ice Events

Staffing Category Number Available / Notes Plow operators

Sidewalk / walkway personnel

Supervisors / dispatch personnel

Backup operators

Attachment C

References

Provide three references for similar commercial, municipal, emergency services, public safety, institutional, or large-facility snow removal work.

Reference 1

Facility / Organization: __________________________________________

Contact Person: _________________________________________________

Phone: _________________________________________________________

Email: __________________________________________________________

Type of Facility: _________________________________________________

Years Serviced: _________________________________________________

Description of Work Performed:

Reference 2

Reference 3

Attachment D

Non-Collusion Affidavit

STATE OF _______________________________ COUNTY OF _____________________________

I, ______________________________________, being duly sworn, depose and state as follows:

1. I am the ______________________________________ of______________________________________, the company that has submitted the attached proposal to the Town of Southington.

2. The proposal is genuine and not collusive or a sham.

3. Neither I nor any member, officer, agent, or employee of the company has, directly or indirectly:

a. Colluded, conspired, connived, or agreed with any other person or company to submit a sham proposal, refrain from submitting a proposal, or otherwise limit competition;

b. Sought by collusion, agreement, communication, or conference with any person to fix the price of this proposal or any other proposal;

c. Attempted to secure, by collusion or any unlawful means, any advantage over the Town of

Southington or any person interested in the proposed contract.

4. All statements contained in the company’s proposal are true and correct.

Company Name: ______________________________________

By: _____________________________________________

Signature of Authorized Representative

Print Name: ______________________________________

Title: ___________________________________________

Date: ___________________________________________

Subscribed and sworn before me this ______ day of ___________, 20__.

Notary Public / Commissioner of the Superior Court:

My Commission Expires: ___________________________

Attachment E

Respondent’s Acknowledgment and Proposal Signature Page

The undersigned bidder acknowledges that they have:

1. Carefully examined all instructions, specifications, terms, and conditions contained in this bid package.

2. Inspected the site or had the opportunity to inspect the site.

3. Received, read, and considered all issued addenda, if any.

4. Completed and included all required forms.

5. Submitted a complete proposal to perform the work specified for the Town of Southington.

6. Confirmed that the bidder has sufficient equipment, staffing, backup capacity, salt supply, and experience to perform snow and ice control services for a 24-hour emergency operations facility.

The undersigned further agrees that, if awarded the contract, the firm will enter into a written agreement with the Town of Southington and perform the work in strict accordance with the bid and contract documents.

Company Name: ______________________________________

Authorized Representative: _________________________

Signature: _______________________________________

Print Name: ______________________________________

Title: ___________________________________________

Address: _________________________________________

City / State / Zip: _________________________________

Phone: __________________________________________

Email: ___________________________________________

Primary 24-Hour Emergency Contact: ________________

Primary 24-Hour Emergency Phone: _________________

Secondary 24-Hour Emergency Contact: ______________

Secondary 24-Hour Emergency Phone: _______________

Date: ____________________________________________