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
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Email *
Name or initials
Grade/Year in School
Name of School
Shoe Size
Please select 1 option for Shirts/Tops:
Clear selection
Select 1 option for bottom size:
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
Please list bra size for girls or young women:
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:
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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
Comments about child's style, favorite colors, or other information to help us optimally customize this care package:
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This form was created inside of Augustana College.