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Thank you for your interest in our services. Once we have received your electronic enrollment forms (keep scrolling to start the application), we will contact you to start service. If you prefer to print the packet and US Mail it back to Cultivate, click here:

Client Packet - Boulder and Broomfield Counties

Client Information

Preferred Language *

English

Spanish

Other:

Service(s) Requested

(Enrollments are full for the 2024 YardBusters season and the 2024-2025 SnowBusters season)

Carry-Out Caravan

Fix-It

VetsGo

PhoneBuddies

SHOP Ramp Building (Weld County Only)

Required

Describe your service request, if you have one:

(e.g. I need grab bars, I need a ride to the VA, etc.)

If you selected the SHOP program and need a mobility ramp, how do you plan to pay for the materials?

Private Pay (check made out to Cultivate)

City of Greeley

Partner Organization

Other

Clear selection

First Name *

Middle Initial

Last Name *

Age *

Birthdate *

YYYY

Gender *

Female

Male

Other:

Preferred Pronouns

Address *

Include City, State and Zip Code

Home Phone Number *

Cell Phone Number

(enter "none" if you don't have a cell phone number)

Preferred Number *

Home Phone

Cell Phone

Email Address *

Enrollment Agreement

I understand that my enrollment in Cultivate programs is not guaranteed and may be discontinued at Cultivate’s discretion if I do not abide by program policies and guidelines. I acknowledge that I will treat all Cultivate staff and volunteers with respect. Cultivate has the right to discontinue my service if I am in violation of this agreement.

I Understand and Agree to the Above

Required

Are you: *

Single

Married

Domestic Partner

Divorced

Widowed

Other:

Monthly Income Range - Individual

This information is collected for demographic purposes only. Eligibility is not determined by income.

$1,041 or less

$1,042 to $1,301

$1,302 to $1,926

$1,927 or more

Other:

Clear selection

Monthly Income Range - Married

This information is collected for demographic purposes only. Eligibility is not determined by income.

$1,409 or less

$1,410 to $1,761

$1,762 to $2,607

$2,607 or more

Other:

Clear selection

Is your income below the federal poverty level listed below? *

Yes

Do you live alone? *

Yes

If no, how many people live in your household?

Do you identify as:

African American/Black

Asian/Asian American

Hispanic/LatinX

Native American/Alaska Native

Native Hawaiian or other Pacific Islander

White/Caucasian

Two or more races

Other:

Clear selection

Are you a member of the LGBT+ community?

Yes

Clear selection

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