Professional Documents
Culture Documents
Instructions
PLEASE COMPLETE THIS FORM ON A COMPUTER (DO NOT HAND WRITE
FORM)
1
Complete all boxes under section 1: Organization Information. Identify the county(ies) impacted by
the proposed work by checking the corresponding box. List each site/building that will be impacted
by your SHIP work separately and provide each sites address. Determine one point of contact per
organization interested in a SHIP mini-grant. One intent form PER organization is allowed. Please
include all the sites wishing to work with SHIP on one form. Identify 1st and 2nd choice for meeting
dates with SHIP staff during the week of August 3rd.
1. Click to select the strategy(ies) your organization would like to work on. More detailed information
on each strategy and the requirements can be found by accessing the Strategy Implementation
Guides listed by each check box as well as SHIP funding requirements in the Financial Guide.
Check the corresponding box to each strategy your organization plans to apply to work on. Within
each of the strategies- select the activities (or sub-strategies) your sites plans to address.
2. Complete this form and letter of commitment and send as an attachment in an e-mail to
leeann.huebsch@fmchs.com with LETTER OF INTENT FORM: (Your Organizations Name) in the
subject heading. Letters of intent are due no later than 5:00p.m. on July 24, 2015.
SHIP 4
Letter of Intent (Non-Binding)
1. Organization Information
Organization Name:
Contact Person
Name/Title:
E-mail:
Phone:
County(ies) impacted:
(please check all counties
this organization will
work in with SHIP
Identify 1st & 2nd Choices
for Meeting with SHIP
Staff during the week of
August 3rd.
Faribault
Martin
Watonwan
1st Choice
Monday August 3
Tuesday August 4
Wednesday August 5
Thursday August 6
Friday August 7
2nd Choice
Monday August 3
Tuesday August 4
Wednesday August 5
Thursday August 6
Friday August 7
Site Name
(please list site name and address if multiple sites,
please list all sites and addresses i.e.- multiple school
buildings, multiple work sites, multiple clinics, etc.)
Site Address
Strategy Activities
(check applicable
boxes)
Active Living
More information
on requirements
Anticipated
Number of
People
Reached (i.e.- #
of students, # of
staff, # of
community
members, #
patients in service
area, etc.):
Activities
Targeted to: (check
applicable boxes)
Target
Populations
Reached (i.e. %
of youth, % of lowincome (free &
reduced lunch), %
uninsured, %
Latino, %
population over 60,
etc.):
Age 60+
Hispanic/Latino
Low Income
Youth
and
implementation
activities can be
found here:
Active Living in
Communities
(PDF)
More information
on allowable uses
of SHIP funding
can be found
here: Financial
Guide (PDF)
Healthy
Schools
*Schools are
required to select
at least 1
physical activity
strategy and 1
healthy eating
strategy.
More information
on requirements
People with
Mental Illness
Other:
____________________
_
Age 60+
Hispanic/Latino
Low Income
Youth
People with
Mental Illness
Other:
____________________
_
and
implementation
activities can be
found here:
Schools - Healthy
Eating and Active
Living (PDF)
More information
on allowable uses
of SHIP funding
can be found
here: Financial
Guide (PDF)
Worksites
*Required to
work on all
strategies:
Healthy Eating,
Physical Activity,
Breastfeeding
Age 60+
Hispanic/Latino
Low Income
Youth
People with
Mental Illness
Other:
____________________
Support and
Tobacco
Policies/Cessation
.
More information
on requirements
and
implementation
activities can be
found here:
Workplace (PDF)
More information
on allowable uses
of SHIP funding
can be found
here: Financial
Guide (PDF)
stations
o
Cafeteria offerings
Catering
Flexible scheduling
Active commuting
Health Care
More information
on requirements
and
implementation
activities can be
found here:
Health Care
(PDF)
More information
on allowable uses
of SHIP funding
can be found
here: Financial
Guide (PDF)
Age 60+
Hispanic/Latino
Low Income
Youth
People with
Mental Illness
Other:
____________________
_
Program
Establish evidence-based strategies to
support clinic-community linkages to
ensure access to the delivery of
preventive services through (Pick one or
more):
Tobacco cessation (e.g., Call It
Quits/Fax Referral Program)
Diabetes Prevention Program
(DPP) Obesity, Healthy Eating and
Physical Activity (e.g., DPP) in a
systematic manner utilizing
evidence-based clinical guidelines
and community referrals to
address Obesity, Healthy Eating
and Physical Activity
Chronic Disease Selfmanagement Program (Obesity,
Healthy Eating, and Physical
Activity (e.g., CDSMP) in a
systematic manner utilizing
evidence-based clinical guidelines
and community referrals to
address Obesity, Healthy Eating
and Physical Activity
Falls Prevention (Healthy Eating
and Physical Activity), in a