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Thank you for your interest in our services. Please download a Client Enrollment Packet from
https://cultivate.ngo/uploads/files/2024-final-client-packet-no-SB.pdf
. This document will provide you information about all of our services and guide you through filling out this form electronically. Once we have received your electronic enrollment forms, we will contact you to start service. Please feel free to call us at 303.443.1933 for additional information. We look forward to serving you.
Client Information
Preferred Language
*
English
Spanish
Other:
Service(s) Requested
(Enrollments are closed for the 2024 SnowBusters season)
*
Carry-Out Caravan
Fix-It
VetsGo
YardBusters
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.)
Your answer
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
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First Name
*
Your answer
Middle Initial
Your answer
Last Name
*
Your answer
Age
*
Your answer
Birthdate
*
MM
/
DD
/
YYYY
Gender
*
Female
Male
Other:
Preferred Pronouns
Your answer
Address
*
Include City, State and Zip Code
Your answer
Home Phone Number
*
Your answer
Cell Phone Number
(enter "none" if you don't have a cell phone number)
*
Your answer
Preferred Number
*
Home Phone
Cell Phone
Email Address
*
Your answer
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:
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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:
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Is your income below the federal poverty level listed below?
*
Yes
No
Do you live alone?
*
Yes
No
If no, how many people live in your household?
Your answer
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:
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Are you a member of the LGBT+ community?
Yes
No
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