For organizations submitting a second program for consideration

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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:
  • 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

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