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 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.

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 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 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
Email address *
Name or initials
Grade/Year in School
Name of School
Shoe Size
Please Select One:
Clear selection
Pant Size
Please Select One:
Clear selection
Top Size
Clear selection
Select One:
Clear selection
If available, would you like us to include hygiene items such as deodorant, shampoo, or body wash in the care package?
Clear selection
If available, does this child need sulfate-free shampoo specialized for natural, curly hair?
Clear selection
If available, would this child like a fleece blanket?
Clear selection
If available, does this child need a winter coat?
Clear selection
For girls/young women: what is bra size?
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 61201 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:
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
Other Comments or Special Instructions
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
Child's Favorite Sports Team
Child's Current School
Is there anything we should NOT include in the care package?
For boys/young men, check all that apply.
For girls/young women, check all that apply.
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