If this is a new request, please submit an online letter of intent. Allow 10 days to receive a response. Consideration is based upon alignment with Baptist Health's mission and strategic priorities. 

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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. Briefly describe organization's mission.  (Character limit 2,000)

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* 6. Contact Person

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* 7. Name of Program/Initiative

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* 8. What is the problem or need addressed by program/initiative? (Character limit 2,000)

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* 9. Who is the targeted population for your program/initiative? (Character limit 2,000)

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* 10. What services are provided by the program/initiative? (Character limit 2,000)

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* 11. What amount are you requesting?

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* 12. List other Funding Sources including the amount. (Character limit 2,000)

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* 13. What is the length of time your organization has implemented this program?

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* 14. Indicate the prioritized population health need the program/initiative will address. (Please check all that apply.)

For questions, contact Lynn Sherman at lynn.sherman@bmcjax.com or (904) 202-5112

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