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 (2623 5th Ave., Unit 102 in Rock Island) on Thursdays between 4-8 pm. For children who have transportation or other barriers, a custom care package may be requested.

Social workers or approved school personnel are invited to submit a care package request if the child for whom you are submitting the form meets the following criteria:

-Between the ages of 5-20. We typically stock sizes youth small through adult.

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

-Lives in the Quad Cities community in Iowa/Illinois.

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

Registered clients 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 *

INFORMATION ABOUT THE CHILD WHO WILL RECEIVE THE CARE PACKAGE

Name or initials

Age

Grade/Year in School

Gender

Name of School

Shoe Size

Please select 1 option for Shirts/Tops:

Adult women's/juniors size EXTRA SMALL (0-3)

Adult women's/juniors size SMALL (4-6)

Adult women's/juniors size MEDIUM (7-9)

Adult women's/juniors size LARGE (10-12)

Adult women's/juniors size EXTRA LARGE (13-16)

Adult women's/juniors size XXL (17-20)

Adult men's/juniors size SMALL

Adult men's/juniors size MEDIUM

Adult men's/juniors size LARGE

Adult men's/juniors size EXTRA LARGE

Adult men's/juniors size XXL

Girl's/youth size SMALL (5-6)

Girl's/youth size MEDIUM (7-8)

Girl's/youth size LARGE (10-12)

Girl's/youth size XL (14-16)

Girl's/youth size XXL (18-20)

Boy's/youth size SMALL (5-6)

Boy's/youth size MEDIUM (7-8)

Boy's/youth size LARGE (10-12)

Boy's/youth size XL (14-16)

Boy's/youth size XXL (18-20)

Other:

Clear selection

Select 1 option for bottom size:

Adult women's/juniors size EXTRA SMALL (0-3)

Adult women's/juniors size SMALL (4-6)

Adult women's/juniors size MEDIUM (7-9)

Adult women's/juniors size LARGE (10-12)

Adult women's/juniors size EXTRA LARGE (13-16)

Adult women's/juniors size XXL (17-20)

Adult men's/juniors size SMALL (waist size 28 or 30)

Adult men's/juniors size MEDIUM (waist size 32 or 34)

Adult men's/juniors size LARGE (waist size 36 or 38)

Adult men's/juniors size EXTRA LARGE (waist size 40 or 42)

Adult men's/juniors size XXL (waist size 44 or 46)

Girl's/youth size SMALL (5-6)

Girl's/youth size MEDIUM (7-8)

Girl's/youth size LARGE (10-12)

Girl's/youth size XL (14-16)

Girl's/youth size XXL (18-20)

Boy's/youth size SMALL (5-6)

Boy's/youth size MEDIUM (7-8)

Boy's/youth size LARGE (10-12)

Boy's/youth size XL (14-16)

Boy's/youth size XXL (18-20)

Other:

Clear selection

If available, would you like us to include hygiene items such as deodorant, shampoo, or body wash in the care package?

Yes

Clear selection

If available, does this child need sulfate-free shampoo specialized for natural, curly hair?

Yes

Clear selection

If available, would this child like a fleece blanket?

Yes

Clear selection

Please list bra size for girls or young women:

INFORMATION ABOUT THE PERSON SUBMITTING THE FORM

Name of person making this referral.

Agency/school affiliation for person making this referral.

Phone number of person making this referral.

When possible, we ask that the person making the referral make arrangements to pick up care packages at our facility, located at 2623 5th Ave., Unit 102, Rock Island, IL any Thursday from 4-8 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:

I will pick up this child’s care package

Nobody from my agency is able to pick up the care package.

Clear selection

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?

If you need the care package delivered, to which agency/organization/school should the care package be delivered?

Address 1

City

State

Comments about child's style, favorite colors, or other information to help us optimally customize this care package:

Submit

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This form was created inside of Augustana College.