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For organizations submitting a second program for consideration

PLEASE NOTE: this application will be updated with the 2022-2024 Community Health Need Priorities in February 2022 following approval by the 5 Baptist Health hospital boards. If you are applying between Oct. 1, 2021 - Jan. 31, 2022 and do not see the need you intend to address in Question 13, please contact Jennifer Donahoo at jennifer.donahoo@bmcjax.com for guidance.

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1. Organization

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2. Tax ID#

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3. Website Address

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4. President or Chief Executive Officer

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5. Organization's Mission

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6. Name of Program Requesting Funding

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7. Funding Amount Requested

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8. What is the problem or need addressed by the program?

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9. Contact Person for Application

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10. Signature of Authorized Person
My signature certifies the organization named above has tax exemption under Internal Revenue Service Code Section 501(c)(3). My name in this space indicates I am authorized to sign on behalf of the applying organization.

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11. Indicate the Baptist Health priority and/or the Community Health Needs Assessment prioritized need the program addresses (select all that apply)

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12. Who is your targeted population?

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13. What are the goals and objectives of your program and how does it fit into your organization's overall mission?  
Please include S.M.A.R.T. attributes.

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14. What the specific measures or data that will demonstrate impact/success?  How will you collect the data?  

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15. If program has been operational in the past, provide outcomes achieved during the previous year. 

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16. What are the titles and qualifications of staff implementing the program?

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17. Identify the biggest challenges or obstacles to successfully implementing the program. How do you plan to overcome them? Are collaborations necessary? 

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18. How many years funding are you requesting?  If more than one, please explain.

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19. If approved, how do you plan to sustain the program once Baptist Health funding ceases?

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20. Does the organization have a board-approved succession plan its executive leader?

Additional Documents Required:
  1. Organizational budget
  2. Program budget - under revenue, please include other financial requests, providing funder names, amounts and status (seeking or secured), including the Baptist Health request
  3. List of board members with affiliations and demographics/ethnicity
  4. Board-approved succession plan or signed certification of board-approved succession plan
  5. Copy of the tax-exempt status determination letter from the Department of the Treasury, IRS
  6. Copy of most recently filed IRS Form 990
  7. Most recent annual report (if available)
To submit:
1. ensure the finalized version is saved in Survey Monkey
2. prepare an email to lynn.sherman@bmcjax.com, copying jennifer.donahoo@bmcjax.com, with the subject line: "Your organization's name - submitting Strategic Investment application"

For questions or concerns, please contact:
Lynn Sherman, Director of Community Engagement 
lynn.sherman@bmcjax.com or 904.202.5112

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