Group List

Date Billing First name Billing Last name Billing Company Billing E-mail Billing Phone Billing City Billing State Variation Order Qty Total _billing_diocese
2022-12-30ChrissyBundrickOur Lady Star of the Sea[email protected]9125527783St. MarysGA15Diocese of Savannah
2022-10-05EvelynFullerSt. Matthew[email protected]908-910-9099TyroneGA8Atlanta
2022-10-05KathleenElySt. Mary's - Bloomington, IL[email protected]309-212-5075NormalIL30Peoria, IL
2022-10-05JaredBlakeSacred Heart, Our Lady's Collaborative[email protected]6173313340NewtonMA40Boston, MA
2022-10-05CathySalehSt Eulalia Parish[email protected]7813685099WinchesterMA35Boston
2022-10-05MikeYoungQuincy Notre Dame High School[email protected]2176176632QuincyIL80Springfield, IL
2022-10-05LaurieDeLucaSt. Stephen Catholic Community[email protected]407-340-7593Winter SpringsFL20Orlando, FL
2022-10-04SusanRaboldSt. Paul the Apostle Catholic Church[email protected]336-210-0843GreensboroNC19Charlotte
2022-10-03St. LouisYouth MinistrySt. Louis Catholic Church[email protected]901-255-1965MemphisTN72Memphis

Total quantity sold : 319

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Camper Paperwork (AKA Applications)

Participant NameNicknameParish / GroupHave you attended CHWC before?How many years?GenderShirt SizeAge Category (at the time of camp)Grade entering in the fall of 2023Cell PhoneEmailFirst Choice Service AssignmentSecond Choice Service AssignmentConstruction:Concrete/Masonry:Drywall:Painting:Plumbing:Electrical:Any comments to help place you on a team?Are there any health issues we need to know about before placing you at a worksite?Other Jobs at CampParticipant Date of BirthEmergency ContactEmergency Contact, Relationship to ParticipantEmergency Contact, Phone NumberHealth Status: Please list any health problems you may havePlease list all medications taken routinely (over the counter and prescription)Physician NamePhysician Phone NumberDate of your last Tetanus BoosterHealth Insurance: ProviderHealth Insurance: Policy NumberHealth Insurance: Group NumberRELEASE OF ALL CLAIMSMEDIA WAIVERCODE OF BEHAVIORParticipant SignatureCustodial Parent NameCustodial Parent SignatureCustodial Parent EmailSIGNATURE AGREEMENTAre you a member of clergy or professed religious?Please SpecifyEntry IDSequence NumberEntry DateDelete Entry Link
Daniel Dyer
Quincy Notre Dame High School
Yes
1
Male
Large
Youth (under 18)
11th
Work project (painting, indoor clean up, maintenance, repair work, outdoor yard work)
Work at a social service center (homeless shelter, food distribution center)
2
1
1
2
1
1
Great teammate. Been involved in team sports/leadership for years. Take direction well.
02/15/2007
Jeremy Dyer
Father
(217) 440-3514
Dr. Go
(217) 222-6550
07/08/2020
Solidarity
242299305
242299305
AGREE
AGREE
AGREE
Jeremy Dyer
AGREE
351
1
Mia Coval
Quincy Notre Dame High School
No
Female
Small
Youth (under 18)
10th
Work with children at day care centers for low-income families
Work at a social service center (homeless shelter, food distribution center)
2
1
1
4
1
1
08/01/2008
Lili Coval
Mother
(636) 887-6966
Fluoxetine 20 mg
Stephany Reyburn
(217) 222-6550
08/16/2019
BSBC-IL
QMG829715061
0EC580
AGREE
AGREE
AGREE
Lili Coval
AGREE
345
2
Jeremy Dyer
Quincy Notre Dame High School
Yes
3
Male
Large
Adult (21 and older)
(217) 440-3514
Work project (painting, indoor clean up, maintenance, repair work, outdoor yard work)
Work at a social service center (homeless shelter, food distribution center)
4
3
5
5
4
4
12/08/1973
Jennifer Dyer
Spouse
(217) 440-9766
Dr. Reyburn
(217) 222-6550
02/20/2018
Solidarity
242299305
242299305
AGREE
AGREE
AGREE
AGREE
No
342
3
Dylan Pruett
Dylan
Quincy Notre Dame High School
Yes
1
Male
Large
Youth (under 18)
11th
Work project (painting, indoor clean up, maintenance, repair work, outdoor yard work)
Work at a social service center (homeless shelter, food distribution center)
2
2
3
2
3
2
I’ve done a lot of this at my home
No
06/12/2007
Sarah Pruett
Mother
(217) 242-3269
No
No
Becky Campbell
(217) 222-6550
07/16/2022
BlueCross BlueShield
TZJ840596401
PB1210
AGREE
AGREE
AGREE
Sarah Pruett
AGREE
340
4
Bayley Weisenberger
Bayley
Quincy Notre Dame High School
No
Female
Medium
Youth (under 18)
10th
Work project (painting, indoor clean up, maintenance, repair work, outdoor yard work)
Work at a social service center (homeless shelter, food distribution center)
2
1
2
4
1
1
N/A
09/01/2008
Kari Weisenberger
Parent
(217) 242-3256
N/A
N/A
Dr. Nathan Seaman
(217) 222-6550
09/24/2019
BCBS
QMF921609690
IB1803
AGREE
AGREE
AGREE
Kari Weisenberger
AGREE
312
5
Natalie Tull
Allie
Quincy Notre Dame High School
Yes
2
Female
Medium
Youth (under 18)
12th
Work with children at day care centers for low-income families
Work at a social service center (homeless shelter, food distribution center)
1
1
1
2
1
1
Allie is fabulous with kids, organizing, cleaning
Allie had a TIA in 2021 which was caused from a PFO (hole) in heart. Heart was closed in Nov 2021 and she only needs to see cardiologist once a year. She also gas tacchychardia. She knows signs and how to track her heart rate.
09/06/2005
Brandy Ridder
Aunt/Guardian
(773) 531-6057
Tacchychardia
Zyrtec 10mg daily
Prozac 30 mg daily
Metoprolol 25mg daily
Vyvanse 20 mg in morning
Dr Divya Batra
(217) 222-6550
04/04/2017
Anthem Blue Cross Blue Shield
MGJ050936MDT
MO2000M013
AGREE
AGREE
AGREE
Brandy Ridder
AGREE
310
6
Benjamin McDonald
Ben
Quincy Notre Dame High School
Yes
1
Male
Large
Youth (under 18)
11th
Work project (painting, indoor clean up, maintenance, repair work, outdoor yard work)
Work at a social service center (homeless shelter, food distribution center)
2
1
1
4
2
2
11/24/2006
Jodi McDonald
mother
(217) 257-4433
Loretta Baustain
(217) 214-9601
06/08/2022
BlueCrossBlueShield
283958
283958
AGREE
AGREE
AGREE
Jodi McDonald
AGREE
307
7
Elena Mast
Lanie
Quincy Notre Dame High School
Yes
1
Female
Medium
Youth (under 18)
11th
Work at a social service center (homeless shelter, food distribution center)
Work project (painting, indoor clean up, maintenance, repair work, outdoor yard work)
1
1
1
3
1
1
01/19/2007
Maria Mast
mother
(217) 257-3135
Dr. Porter
(217) 222-6550
08/08/2018
United Heathcare
991547087
926213
AGREE
AGREE
AGREE
Maria Mast
AGREE
301
8
Avery Crane
Quincy Notre Dame High School
Yes
1
Female
Medium
Young Adult (18-20)
(573) 406-3276
Work with children at day care centers for low-income families
Work at a social service center (homeless shelter, food distribution center)
2
1
1
3
1
1
07/28/2007
sarah crane
mom
(573) 406-3276
Dr Tolbert
(217) 223-8400
01/25/2023
BCBS
363/865
NLM363
AGREE
AGREE
AGREE
AGREE
No
300
9