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Application for an atmosphere System from the Marilyn Thoms Memorial Fund for Veteran Wellness
Giving Mac 501(c)(3) Public Charity
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Address
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Afghanistan
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Anguilla
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Brazil
Brunei
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Burkina Faso
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Canada
Cape Verde
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Chad
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China
Christmas Island
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Colombia
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Jersey
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Kuwait
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Latvia
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Libya
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Lithuania
Luxembourg
Macau
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Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
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Mongolia
Montenegro
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Nicaragua
Niger
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Portugal
Puerto Rico
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Republic of the Congo
Romania
Russia
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Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
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Samoa
San Marino
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Senegal
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Switzerland
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Taiwan
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Tanzania
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Tokelau
Tonga
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Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
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Uganda
Ukraine
United Arab Emirates
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United States
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Uzbekistan
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US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
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Other
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
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3
Contact Person
First Name
Last Name
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4
Position/Title
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5
Phone Number
Area Code
Phone Number
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6
Email
example@example.com
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7
Facility Information
VA Medical Centers
State Veterans Homes
VA Community Living Centers
VA Outpatient Clinics
Vet Centers for Counseling
Veterans Affairs Transitional Housing Programs
Veterans Affairs Mental Health Centers
Veterans Rehabilitation Centers
Veterans Community-Based Outpatient Clinics
Veterans Assisted Living Facilities
Veterans Homeless Shelter
Veterans Affairs Hospice and Palliative Care Unit
Veterans Post
Specialized Retreat for Veterans
Other
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8
Describe any current mental wellness programs, formal or informal, available at your facility.
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9
Why is your facility interested in the atmosphere system?
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10
How do you anticipate the atmosphere system will benefit your veterans and the employees of your facility?
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11
Please provide any additional information or specific needs your facility has regarding mental wellness programs.
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12
Are you able to contribute to the funding of the atmosphere system?
Yes
No
Maybe
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13
If yes, please specify the amount or type of contribution.
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14
If no, please describe any potential funding sources or sponsorships you are seeking.
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If Maybe, please explain.
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16
Projected project timeframe.
Now to 2 months
More that 4 months
2 to 4 months
No time frame
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17
Would you be able to travel to Eau Claire, WI to experience an atmosphere system and discuss potential display, sound and lighting system option?
Yes
No
Maybe
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18
Name of person completing application.
First Name
Last Name
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19
Agreement and Signature
By signing below, you confirm that the information provided is accurate to the best of your knowledge and if chosen, agree to collaborate with Giving Mac to enhance mental wellness of veterans through an atmosphere system.
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20
Please verify that you are human
*
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