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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

(Enrollment for the 2025-2026 SnowBusters season and 2025 YardBusters season is full)

Carry-Out Caravan

Fix-It

VetsGo

PhoneBuddies

SHOP Ramp Building (Weld County Only)

Required

Chore Service Requested:
*

Do you need help performing this chore? *

Yes

Reason why you need help performing this chore? (e.g. specific medical diagnosis, balance issues, mobility limitations, fall risk, etc) *

Do you have reliable outside support for home safety, maintenance tasks or transportation? (Family, friends, caregiver, etc)

Yes

Clear selection

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

Non-binary

Transgender

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:

Is your income above or below the amount listed for household size? *

Above

Below

Do you live alone? *

Yes

If no, how many people live in your household?

Health Insurance (select all that apply): *

Medicare

Medicare Advantage

Medicaid

Medicaid Waiver(s)

Private

None

Other Insurance

Refuse to answer question

Required

Can you access this service through another benefit program? For example, through Medicaid or Medicare benefits? *

Yes

I don't know

Refuse to answer question

Do you identify as:

Asian/Asian American

Black / African American

Hispanic/LatinX

Middle Eastern / N. African

Native American/Alaska Native

Native Hawaiian or other Pacific Islander

White, non-Hispanic

Two or more races

Other:

Clear selection

Are you a member of the LGBT+ community?

Yes

Clear selection

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