GP Car Clinic Client Sign Up Form
Welcome! This form is to sign up for the Grace Place Car Care Clinic. This clinic is designed especially for single mothers and widows in need. It is run entirely by volunteers from the church community using the space donated by B-Town Automotive at 912 N. 2nd Street in Berthoud. Clients who attend are given an oil change as well as a basic car inspection. This is done free of charge but we do ask that each client bring an oil filter specific to your car. If you would like your air filter changed you may also bring an air filter specific to your car but that maintenance is only required about once a year. We are unable to provide synthetic oil at this time but do provide conventional oil free of charge.

The more information you can put on this form the less we will have to fill out when we call you. All information is used only for our clinic so that we may serve you better. The vehicle information and the VIN number assures that we put the correct type/amount of oil into your car and enables us to be ready with the correct supplies when you arrive. We will not share or sell your information.

Still have questions? Feel free to call Diana Austin 303-250-5418 or Jordan Austin 303-619-7358.

First Name *
Your answer
Last Name *
Your answer
Phone Number
Your answer
Email Address
Your answer
Address
Your answer
This clinic is designed especially for single mothers and widows in need. Does this describe you? *
Car Make, Model, and Year (example: 2002 Toyota Camry):
Your answer
Current Mileage:
Your answer
VIN (Vehicle Identification Number can be found on your insurance card or on your dashboard where the windshield and dashboard meet, typically on the driver side):
Your answer
I understand that I need to bring an oil filter that is specific to my car.
Time of day requested:
Do you have any specific concerns with your vehicle?
Your answer
Anything else that we should know?
Your answer
Submit
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