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Baptist Health Strategic Investment Application 2018

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

Question Title

* 1. Organization

Name *

Address *

City/Town

ZIP/Postal Code *

Email Address *

Phone Number *

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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 (Briefly describe. Character limit 2,000)

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* 6. Do you have a board-approved Succession Plan for your CEO/Executive Director?

Yes

If no, please indicate the date by which you expect to have a board-approved Succession Plan.

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* 7. Funding Amount Requesting for Program/Initiative

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* 8. Name of Program/Initiative Requesting Funding

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

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* 10. Contact Person for Application

Name

Email Address

Phone Number

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* 11. Signature of Authorized Person

My signature certifies that 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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* 12. Indicate the prioritized population health need the program/initiative will address. (Select all that apply.)

Access to health care for children

Access to care for adults

Access to Care for the Elderly

Communicable Diseases

Health Disparities

Mental Health

Obesity/Nutrition/Lifestyle

Diabetes

Smoking

Cancer

Unprotected Sex/Teen Pregnancy

Maternal and Child Health: ______ Infant Mortality

Unintentional Injury

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* 13. Who is your targeted population? (Character limit 2,000)

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* 14. What are the goals and objectives of your program/initiative and how does it fit into your agency’s overall mission? (Character limit 2,000)

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* 15. How will you measure impact? (Character limit 2,000)

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* 16. If program has been operational in the past, provide outcomes achieved during the previous year. (Character limit 2,000)

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* 17. What are the titles and qualifications of staff implementing the program/initiative? Resumes are not necessary.
(Character limit 2,000)

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* 18. Identify the biggest challenges or obstacles to successfully implementing the program/initiative. How do you plan to overcome your challenges? Are collaborations necessary? (Character limit 2,000)

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* 19. How many years of funding are your requesting?

One

Two

Three

If more than one year, please explain.

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* 20. What are your plans to sustain the program/initiative if funding is approved? (Character limit 2,000)

20. Additional Documents Required:

Organization's budget
Program/Initiative Budget that includes all sources of funding and details your request for Baptist investment
Copy of organization's tax-exempt status
List of Board Members with affiliations and demographics/ethnicity
Board-approved Succession Plan or signed certification of board-approved Succession Plan
Most recent completed 990
Most recent annual report (if available)

Email documents to: lynn.sherman@bmcjax.com

For questions or concerns contact:
Lynn Sherman, Director of Community Engagement for Social Responsibility
lynn.sherman@bmcjax.com or 904.202-5112
Subject line: Strategic Investment Attachments - Your Organization's Name

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 (Briefly describe. Character limit 2,000)

Question Title

* 6. Do you have a board-approved Succession Plan for your CEO/Executive Director?

Question Title

* 7. Funding Amount Requesting for Program/Initiative

Question Title

* 8. Name of Program/Initiative Requesting Funding

Question Title

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

Question Title

* 10. Contact Person for Application

Question Title

* 11. Signature of Authorized Person My signature certifies that 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

* 12. Indicate the prioritized population health need the program/initiative will address. (Select all that apply.)

Question Title

* 13. Who is your targeted population? (Character limit 2,000)

Question Title

* 14. What are the goals and objectives of your program/initiative and how does it fit into your agency’s overall mission? (Character limit 2,000)

Question Title

* 15. How will you measure impact? (Character limit 2,000)

Question Title

* 16. If program has been operational in the past, provide outcomes achieved during the previous year. (Character limit 2,000)

Question Title

* 17. What are the titles and qualifications of staff implementing the program/initiative? Resumes are not necessary. (Character limit 2,000)

Question Title

* 18. Identify the biggest challenges or obstacles to successfully implementing the program/initiative. How do you plan to overcome your challenges? Are collaborations necessary? (Character limit 2,000)

Question Title

* 19. How many years of funding are your requesting?

Question Title

* 20. What are your plans to sustain the program/initiative if funding is approved? (Character limit 2,000)

* 11. Signature of Authorized Person

My signature certifies that 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.

* 17. What are the titles and qualifications of staff implementing the program/initiative? Resumes are not necessary.
(Character limit 2,000)