Care Package Request Form
Thank you for your interest in our programs. When possible, we invite children who meet the criteria listed below to shop with us in person at our facility (2613-5th Ave in Rock Island) on Thursdays between 4-8 pm or on the second or fourth Sundays of each month from 1-3 pm. For children who have transportation or other barriers, a custom care package may be requested.

Please feel free to submit a care package request if the child for whom you are submitting the form meets the following criteria:

-Between the ages of 8-20 (we stock sizes youth medium through adult)

-Currently a foster child or is experiencing homelessness or has other significant circumstances resulting in access to properly fitting, age appropriate clothing

-Lives in the Quad Cities community

Please note that contents of packages are subject to inventory availability.

Children may receive care packages up to 4 times per year.

If you have questions, please call or text 309-235-8786 or email info@closet2closet.org

Email address *
INFORMATION ABOUT THE CHILD WHO WILL RECEIVE THE CARE PACKAGE
Name
Your answer
Age
Your answer
Grade/Year In School
Your answer
Gender
Your answer
Name of School
Your answer
Shoe Size
Your answer
Please Select One:
Pant Size
Your answer
Please Select One:
Top Size
Select One:
If available, would you like us to include hygiene items such as deodorant, shampoo, or body wash in the care package?
For girls/young women: what is your bra size?
Your answer
INFORMATION ABOUT THE PERSON SUBMITTING THE FORM
Name of person making this referral.
Your answer
Agency/school affiliation for person making this referral.
Your answer
Phone number of person making this referral.
Your answer
When possible, we ask that the person making the referral make arrangements to pick up care packages at our facility, located at 2613-5th Ave. in Rock Island any Thursday from 4-8 pm or on the second and fourth Sundays of each month from 1-3 pm. If you have extenuating circumstances and need a care package delivered within the Quad Cities area only, please note that we only deliver to schools or agencies (not private residences) and it may take up to 10 days for packages to be delivered.Please select an option below:
If you will pick up this child’s care package, using the schedule listed above as a guide, what date will you be picking it up?
Your answer
If you need the care package delivered, to which agency/organization/school should the care package be delivered?
Your answer
Address 1
Your answer
City
Your answer
State
Your answer
Country
Your answer
Other Comments or Special Instructions
Your answer
OPTIONAL BUT HELPFUL INFORMATION
The questions that follow are optional, but we appreciate the requester responding to them, if possible. If this information is not known, we are still able to provide a care package with size/gender information completed. We’d like to try to provide wardrobes that fit your personality and style. We do our best to individualize care package contents, so it helps if the requester provides some details for us. Please tell us as much as possible!
Child's Favorite Colors
Your answer
Child's Favorite Sports Team
Your answer
Child's Current School
Your answer
Is there anything we should NOT include in the care package?
Your answer
For boys/young men, check all that apply.
For girls/young women, check all that apply.
Submit
Never submit passwords through Google Forms.
GoogleForms
This form was created inside of Augustana College.