Impact Report for Baptist Health Strategic Investments 2019

Please complete and return this form, along with the narrative, by October 31st.

Question Title

* 1. Contact Information:

Organization Name

Executive Director

Mailing Address

City

State

ZIP/Postal Code

Email Address

Phone Number

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* 2. Project/Program Name:

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* 3. Program Dates:

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* 4. Program Dates (Start/Finish):

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* 5. Amount funded by Baptist Health:

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* 6. Purpose of funding:

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* 7. Number of people served through funding?

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* 8. Have you had any changes in your organizational leadership since this investment was awarded and/or do you anticipate any changes? If yes, please explain:

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* 9. Does your organization have a succession plan for the ED/CEO that has been approved by the Board of Directors? If yes, please attach the plan to this report.

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* 10. Have there been any changes to your organization’s IRS 501(c) (3) nonprofit status since you were awarded this funding? If yes, please explain:

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* 11. I hereby certify that the above and attached statements are true and accurate.
Signature of Executive Director or Authorized Person

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* 12. Attach your leadership succession plan here.

PDF, DOCX, DOC file types only.

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Question Title

* 1. Contact Information:

Question Title

* 2. Project/Program Name:

Question Title

* 3. Program Dates:

Question Title

* 4. Program Dates (Start/Finish):

Question Title

* 5. Amount funded by Baptist Health:

Question Title

* 6. Purpose of funding:

Question Title

* 7. Number of people served through funding?

Question Title

* 8. Have you had any changes in your organizational leadership since this investment was awarded and/or do you anticipate any changes? If yes, please explain:

Question Title

* 9. Does your organization have a succession plan for the ED/CEO that has been approved by the Board of Directors? If yes, please attach the plan to this report.

Question Title

* 10. Have there been any changes to your organization’s IRS 501(c) (3) nonprofit status since you were awarded this funding? If yes, please explain:

Question Title

* 11. I hereby certify that the above and attached statements are true and accurate. Signature of Executive Director or Authorized Person

Question Title

* 12. Attach your leadership succession plan here.

* 11. I hereby certify that the above and attached statements are true and accurate.
Signature of Executive Director or Authorized Person