Letter of Inquiry Submission Form


Thank you for your interest in working with the Blue Cross & Blue Shield of Mississippi Foundation. The Foundation provides targeted grants for health and wellness projects that typically span a one-year period of time. The initiatives funded by the Foundation have a focus on healthy eating and exercise, with measurable outcomes demonstrating improvement in the health of Mississippians.

To be eligible for a grant from the Blue Cross & Blue Shield of Mississippi Foundation, your organization must:

  • Be physically located in Mississippi
  • Benefit the communities in Mississippi
  • Serve the community with no discrimination by age, race, gender, religion, sexual orientation, or disability
  • Not duplicate or significantly overlap the work of public agencies
  • Be one of the following: 1) 501(c)(3) charitable organization (but not a private foundation) and provide proof of such current designation in the form of an IRS determination letter; 2) Municipality; 3) University or College; or 4) K-12 School
  • Cannot have a contractual relationship with Blue Cross & Blue Shield of Mississippi, its subsidiaries or affiliates

The first step in applying for a Blue Cross & Blue Shield of Mississippi Foundation grant is to submit a brief Letter of Inquiry. Please type directly into the form below to make your submission. It is important to not copy text from another document and paste it into this form because that can cause errors when you submit your inquiry, including preventing some text from submitting. Once your Letter of Inquiry has been reviewed, you will receive one of the following:

  • A request for more information
  • A request for a full grant application
  • A letter informing you that the Foundation has elected not to fund your project


Please provide a response to all items.
Contact Information for Individual Submitting Letter of Inquiry:

*1) Salutation (Dr., Rev., Mr., Mrs., etc.): *4) Your email:




*2) First Name: *5) Your phone:




*3) Last Name: *6) Relationship to Requesting Organization:


   
Information Regarding Requesting Organization:

*7) Organization Name (legal name):

*8) Organization Type
501(c)(3)
Municipality
University or College
K-12 School

9) If 501(c)(3), Organization's Tax ID number:


10) Website URL of requesting organization:


*11) Does the organization have a smoke-free environment on all organization-owned property?
Yes No
If no, does the organization have plans to implement a smoke-free environment on all organization-owned property?
Yes No

*12) Does the organization have a tobacco-free (smokeless) environment on all organization-owned property?
Yes No
If no, does the organization have plans to implement a tobacco-free (smokeless) environment on all organization-owned property?
Yes No

*13) Does the organization have an electronic smoking device-free environment on all organization-owned property?
Yes No
If no, does the organization have plans to implement an electronic smoking device-free environment on all organization-owned property?
Yes No

*14) Salutation of Executive Representative: *19) Organization Address(line 1):




*15) First Name of Executive Representative: 20) Organization Address(line 2):




*16) Last Name of Executive Representative: *21) Organization City:


*17) Email of Executive Representative: *22) Organization ZIP Code:



*18) Phone of Executive Representative: *23) Organization County:


Information Regarding Proposed Initiative:

*24) Which of the Foundation's areas of interest does the proposed initiative align:
Healthy Eating
Exercise
Healthy Eating and Exercise

*25) Name of proposed initiative:


*26) Briefly describe the proposed initiative:


*27) Number of individuals your organization will impact by the proposed initiative:


28) List 3 to 5 measurable goals the proposed initiative seeks to address:
*Goal 1:


*Indicate how Goal 1 will be measured:


*Goal 2:


*Indicate how Goal 2 will be measured:


*Goal 3:


*Indicate how Goal 3 will be measured:


Note: A minimum of 3 measurable goals is required; however, you may indicate a maximum of 5 measurable goals.

Goal 4:


Indicate how Goal 4 will be measured:


Goal 5:


Indicate how Goal 5 will be measured:


Of the above, indicate which goals will result in an improvement in health measurement (click at least one of the goals)
Goal 1
Goal 2
Goal 3
Goal 4
Goal 5

*29) Provide an estimate of the project's total budget (Numbers Only):


*30) Indicate the amount of financial support you seek from the Blue Cross & Blue Shield of Mississippi Foundation (Numbers Only):


*31) Summarize how Foundation funds will help achieve the goals of the proposed initiative:


*32) Provide details of other funders approached and details of any funding already received for the proposed initiative:


*33) If funded by the Foundation, explain how the proposed initiative can become sustainable:


* Required Fields