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Car Care Application

Please complete the entire application as failure to do so will automatically disqualify you for assistance.

*Indicates a required field

TO QUALIFY FOR SERVICES from Pearl Promise for you or your child(ren), you must:

Be a single parent with at least 50% legal custody to a child/children under 18 years of age
Reside in Boulder County (preference in services are first given to St. Vrain Valley School District Residents)
Be receiving some form of government of public assistance
Be motivated to become self-sufficient

Before you Begin:

We estimate that the application will take about 30-45 minutes to complete.
You will need to submit images of the following documents (cell phone photos are accepted):
-Driver’s License
-Vehicle Registration
-Vehicle Insurance

Basic Information

Today's Date*

First name*

Last name*

Email*

Phone*

Can you receive texts at the above number?*

Yes

No

Preferred Method of Contact*

Phone

Text

Email

Date of Birth*

Eligibility Confirmation

Are you a single parent with legal custody of at least one child under the age of 18?*

Yes

No

If yes, please list the names and ages of your children

Do you currently reside in Boulder County Saint Vrain School District*

Yes

No

Are you currently employed?*

Yes

No

File upload*

List all monthly income. Please break down including, salary, child support, Social Security, disability benefits, etc.)*

List all monthly expenses including rent/mortgage, utilities, phone, car payment, insurance, gas, food, medical expenses, etc. individually below (Please label e.g. rent - $10000, Utilities - $100, etc.)*

Do you have a valid driver's license?*

Yes

No

Please load your drivers license below.

Drivers License Upload

Do you have proof of car insurance?*

Yes

No

Please load your proof of insurance below.

Proof of Insurance

Vehicle Information

Vehicle Registration Document

Make, Model, and Year of Your Vehicle:*

License Plate Number:*

Is the car drivable?*

Yes

No

Have you taken your car to a repair shop?*

Yes

No

Other

If yes, please describe what work was done.

What is your vehicle primarily used for? (select all that apply)*

Work

School

Medical Appointments

Childcare

Other

When was your last oil change?*

Are there any current concerns or issues with your vehicle's safety or operation? (Please describe below)*

How would participation in our car care clinic help you on your journey toward self-sufficiency?*

We collect this information below in order to receive grant funding as a nonprofit. We do not share outside the organization.

Are you currently receiving any form of government assistance? (Please select all that apply)*

TANF

WIC

CHP+

Medicaid

SSI

SNAP

CCAP

Homelessness

None

Other

What other resources (non-government) have you received assistance from in the last 6 months?*

Child Support

OUR Center

A Woman's Work

Food Banks

None

Other

Are you currently enrolled in higher education?*

Yes

No

If yes, what are you studying?

List any education assistance you are receiving (student loans, grants, etc.) If none, please indicate.*

Pearl Promise Program Participation

Have you participated in any Pearl Promise programs before? (Please select all that apply)*

Transportation

Focus Pearls

Pearl Kids

G.E.M.S.

Kids Mentoring

None

Other

Have you received any services from Pearl in the last two years?*

Car Care Clinic

Car Repairs

Vehicle Donation

Assistance with groceries and/or gas

Utility / bill assistance (fill in amount in other)

None

Other

Is there anything else you'd like us to know about your situation? If none, please indicate below:*

How did you hear about the Car Care Maintenance Program?*

Pearl Promise highly encourages giving back through volunteering time. Are you able to become a Pearl volunteer?*

Yes

No

Have you volunteered with Pearl Promise in the past?*

Yes

No

If yes, please describe how you volunteered?

While Pearl highly recommends that clients attend a spiritual support group and/or meeting, church attendance is NOT required to be a recipient of assistance.

Are you currently attending a weekly spiritual support group and/or meeting?*

Yes

No

If yes, where and how often do you attend?

In the last year, have you had any major life changes? (i.e. new job, new home, new illness, relationship change, etc.)*

Yes

No

If yes, please describe below:

What is your current plan to reach self-sufficiency? (e.g. attend school, buy a car, start applying for higher paying job, etc.)*

Are you on schedule to accomplish these goals? Please explain.*

By providing your electronic signature below, you agree that you meet the qualifications of Pearl Promise (see above) for assistance. Furthermore you agree to all policies and stipulations given with any possible assistance. *

Sign in the box or use the keyboard to type.

Signature field is empty.

PEARL is a Christ-centered organization providing single-parent families the hope and skills necessary to build an economically and emotionally stable home environment through sustainable programs.

PEARL Promise

P.O. Box 1825

Longmont 80502

info@pearlpromise.org

©2025 by PEARL Promise

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