Notice of Intent to ApplyBuilding Healthy Communities

This Notice of Intent to Apply is due by midnight on Feb. 12, 2010. In reply, we will e-mail a confirmation to you. Please visit bcbsm.com/buildhealth to download application forms.

The following school is notifying Blue Cross Blue Shield of Michigan its intent to apply for the Building Healthy Communities: Engaging Elementary Schools and Community Partners grant. The Notice of Intent to Apply does not bind the school to actually applying.

Question Title

Elementary school information

School name:

School district:

City:

County:

Question Title

School principal

Name:

Phone:

E-mail:

Question Title

Primary contact/champion

Name:

Job title:

Primary contact phone:

Primary contact e-mail:

Question Title

Number of students in the school:

Question Title

Number of academic classrooms in the school:

Question Title

The school plans to apply for these community portions of the grant:

Promoting Active Communities assessment

Safe Routes to School assessment

Promoting Active Communities implementation

None of the above

To submit this Notice of Intent to Apply, please click Done below. It will be submitted and this browser window will close.