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Baptist Health Fiscal Year 2020 Strategic Investment Application

Please complete the application. A confirmation of receipt will be sent to you within 48 hours.

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* 1. Organization

Name

Street Address

City

Zip Code

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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

Name & title:

Email Address

Phone Number

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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)

All children in Northeast Florida have healthcare

Adults living in need have access to quality healthcare

Elderly people live independent, fulfilling lives

Access to Care

Behavioral Health

Maternal, Fetal and Infant Health

Vulnerable Population: LGBT+

Vulnerable Population: Seniors

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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?

Yes

Baptist Health funding is contingent upon your organization having a board-approved succession plan for its executive leader.

Additional Documents Required:

Organizational budget
Program budget - please include other financial requests, providing funder names, amounts and status (seeking or secured), including the Baptist Health request.
List of board members with affiliations and demographics/ethnicity
Board-approved succession plan or signed certification of board-approved succession plan
Copy of the tax-exempt status determination letter from the Department of the Treasury, IRS
Copy of most recently filed IRS Form 990
Most recent annual report (if available)

Email documents to:
lynn.sherman@bmcjax.com and copy jennifer.donahoo@bmcjax.com
subject line: Strategic Investment Attachments - Your Organization's Name

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

Question Title

* 1. Organization

Question Title

* 2. Tax ID#

Question Title

* 3. Website Address

Question Title

* 4. President or Chief Executive Officer

Question Title

* 5. Organization's Mission

Question Title

* 6. Name of Program Requesting Funding

Question Title

* 7. Funding Amount Requested

Question Title

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

Question Title

* 9. Contact Person for Application

Question Title

* 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.

Question Title

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

Question Title

* 12. Who is your targeted population?

Question Title

* 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.

Question Title

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

Question Title

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

Question Title

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

Question Title

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

Question Title

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

Question Title

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

Question Title

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

* 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.

* 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.