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
2022-11-22JacobPetersonSt. James[email protected]12317369420MontagueMI10Grand Rapids
2022-10-17DavidCampoOur Lady Comforter of the Afflicted[email protected]8572512372WalthamMA15Boston
2022-10-05DebbiKoeberleinSt Thomas/St Mary's[email protected]2173692641PhiloIL60Peoria Illinois
2022-10-05MicheleEickmanSt. Mary's Catholic Church[email protected]6412952194RomeGA30Atlanta
2022-10-05AnneJoyceReading Catholic Collaborative[email protected]7814248904ReadingMA20Boston
2022-10-05SaraiMyersSt. Edward[email protected]713-979-6831SpringTX28Galveston Houston
2022-10-05KatieKellySt. Michael Catholic Church[email protected]952-447-9056Prior LakeMN74St. Paul & Minneapolis
2022-10-05BethanneMaus-SchaeferSt. Leonard Catholic Church[email protected]262-679-0880MuskegoWI40Milwaukee
2022-10-05KristinHauserSt. Thomas More[email protected]919-942-6240Chapel HillNC25Raleigh
2022-10-01GailWatsonSt. Charles Borromeo[email protected]8284132840MorgantonNC40Charlotte

Total quantity sold : 342

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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
Joseph Sher
St. Michael Catholic Church
Yes
1
Male
Medium
Young Adult (18-20)
(612) 759-9585
Work project (painting, indoor clean up, maintenance, repair work, outdoor yard work)
Work with children at day care centers for low-income families
2
1
1
4
1
1
11/09/2004
Karen Sher
Mother
(612) 965-2736
Dr. Rob Leher
(952) 226-2600
07/25/2017
Blue Cross Blue Shield
JZH132961866001
10778450
AGREE
AGREE
AGREE
AGREE
No
292
1
Keaton Daniel
St. Michael Catholic Church
No
Male
Medium
Youth (under 18)
12th
Work project (painting, indoor clean up, maintenance, repair work, outdoor yard work)
Work with children at day care centers for low-income families
1
1
1
2
1
1
02/14/2006
Jason Daniel
Dad
(952) 412-9040
Type 1 Diabetes
Insulin
Brandon Nathan
(952) 237-4694
09/13/2018
Cigna
U21989822
3341246
AGREE
AGREE
AGREE
Andrea Daniel
AGREE
287
2