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
2022-11-15DianaLoutschSt. Edward[email protected]9528357101BloomingtonMN21Archdiocese of St. Paul and Minneapolis
2022-11-15JohnPowenHoly Cross Parish Community Room or via Zoom[email protected]708-906-5802DeerfieldIL20Archdiocese of Chicago
2022-11-14SarahCaseySt. Elizabeth Ann Seton[email protected]3193933778HIAWATHAIA14Archdiocese of Dubuque
2022-11-14TracyStockerSt. John XXIII Parish (IA)[email protected]13198463139Cedar RapidsIA22Dubuque
2022-11-14Deacon JimNovakSacred Heart Catholic Church[email protected]940-889-5252SeymourTX12Fort Worth, Tx.
2022-11-10MariaHaasSaints John and Paul Parish[email protected]5635068711AltoonaIA10Des Moines
2022-11-04AlexQuiñonesSt. Ignatius[email protected]281-290-4623SpringTX35Galveston-Houston
2022-10-25ClaireParrulli-LowtherSt. John XXIII (NM)[email protected]5053232750AlbuquerqueNM20Santa Fe
2022-10-13JocelynJohnsonOur Lady of Peace[email protected]3202507319MinneapolisMN10St. Paul & Minneapolis
2022-10-05KatieDellSt. Jude[email protected]2149442087AllenTX16Dallas
2022-10-05WendyWandroImmaculate Conception[email protected]6412281071Charles CityIA30Dubuque
2022-10-05TylerRiedSt. Alexander[email protected]3098262049Palos HeightsIL16Chicago
2022-10-05DebMalcomChurch of St. Benedict[email protected]918-455-4451Broken ArrowOK30Tulsa
2022-10-05JohnSobolSt. Elizabeth Seton and St. Stephen Deacon and Martyr[email protected]708-986-2446Orland HillsIL16Archdiocese of Chicago
2022-10-05KatieSmithSt. Joseph[email protected]9792551684RichardsonTX25Dallas
2022-10-05CatherineCampbellSt. Columbkille[email protected]402-339-3285PapillionNE36Archdiocese of Omaha
2022-10-05JimWelchSt. Mary of Vernon[email protected]224-531-7454Indian CreekIL26Chicago
2022-10-03EvelynGarfiasSt. Walter[email protected]6304415036RoselleIL25Joliet
2022-10-03ConnieBrunswickSt NIcholas[email protected]9376233865OsgoodOH5Cincinnati

Total quantity sold : 389

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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
Jocelyn Johnson
Our Lady of Peace
Yes
5
Female
Medium
Adult (21 and older)
(320) 250-7319
Work at a social service center (homeless shelter, food distribution center)
Work project (painting, indoor clean up, maintenance, repair work, outdoor yard work)
2
1
1
3
1
1
07/11/1994
Tracy Johnson
mother
(320) 290-2847
seasonal allergies, allergy-induced asthma, hypothyroidism, endometriosis
levothyroxine, 25mg/day, hypothyroidism
progesterone, 200mg/day 10 days/month, endometriosis
naproxen (as needed for endometriosis/menstrual cramps)
antihistamine (as needed for seasonal allergies)
albuterol inhaler (as needed for allergy-induced asthma)
Cheryl McKee
(651) 653-0062
10/23/2013
Blue Cross Blue Shield
JZH133421246001
10292561
AGREE
AGREE
AGREE
AGREE
No
321
1
Daniel Nitz
Daniel
St. Mary of Vernon
Yes
1
Male
Large
Youth (under 18)
11th
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
2
1
1
N/A
N/A
07/03/2007
Christine Nitz
Mother
(847) 602-2497
seasonal allergies. prescription for ADHD & general anxiety.
Dexmethylphenidate* 20mg (aka Focalin)
Sertraline 50 mg (aka Zoloft)
Guanfacine 3mg (aka Intuniv)
seasonal allergy medicine like "Claritin"
Dr. Dimple Damani c/o Pediatric Partners
(847) 362-4155
08/23/2018
Blue Cross Blue Shield
LJX835968699
256922
AGREE
AGREE
AGREE
Christine Nitz
AGREE
234
2