Request an Application

Please fill out the information below to request an application. You should receive a confirmation email a few minutes after clicking the submit button. Further instructions will be included in this email.

Contact Information

* Town/City Name This field is required This field is limited to 30 characters This field can only contain letters, spaces, dashes, periods, and apostrophes

* Contact Title This field is required This field is limited to 50 characters

* Contact First Name This field is required This field is limited to 35 characters This field can only contain letters, spaces, apostrophes and dashes

* Contact Last Name This field is required This field is limited to 60 characters This field can only contain letters, spaces, apostrophes and dashes

* Contact E-mail Address This field is required Please enter a valid Email address This field is limited to 70 characters

* Contact Phone Number This field is required Please enter a valid phone number

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Disclaimer

Print Version By checking this box, I agree as an eligible Mississippi Town/City to the Healthy Hometown Awards Disclaimer

Disclaimer

The Blue Cross & Blue Shield of Mississippi Foundation and its parent company Blue Cross & Blue Shield of Mississippi, A Mutual Insurance Company disclaim any liability in connection with your participation in the Healthy Hometown Awards program or your application for the Healthy Hometown Awards. The Applicant Town/City hereby assumes all liability for any activities undertaken in connection with the application for the Healthy Hometown Awards Program or any activities resulting from that application or the use of any award should one be given. The Applicant Town/City will hold harmless and indemnify the Blue Cross & Blue Shield of Mississippi Foundation and its parent company, Blue Cross & Blue Shield of Mississippi, A Mutual Insurance Company from and against any and all liability arising in connection with Applicant Town/City’s application for the Healthy Hometown Awards program.

All decisions regarding the Healthy Hometown Awards Program including the making of awards are solely in the discretion of the Blue Cross & Blue Shield of Mississippi Foundation. Any such decisions are final and not subject to review or revision, and the Blue Cross & Blue Shield of Mississippi Foundation and Blue Cross & Blue Shield of Mississippi, A Mutual Insurance Company hereby disclaim any and all liability associated with any decision regarding the Healthy Hometown Awards Program including the making the awards.

Please review the Disclaimer before completing the Healthy Hometown Awards Application. By completing the Healthy Hometown Awards Application you acknowledge that you have read and understand the Disclaimer.

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Application Request Submitted

Your application request has been submitted. A confirmation has been sent to {{emailSentTo}}.